(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Biodiversity Heritage Library | Children's Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Harvard medical alumni bulletin"

SPRING/SUMMER 2007 



l^fEl 



DESIGN 

FOR 
HEALINi 



'vard rolls 
out a medical 
curriculum 
for the twenty- 
first century. 




'•■^tU^: 



f 




As dean of Harvard Medical Sch. 
from 1 965 to 1 977, Robert Ebert 
championed numerous initiatives 
that today help define the very 
character of the School. He 
increased recruitment and enroll- 
ment of minority students, estab- 
lished affiliations between HMS 
teaching hospitals and neighbor- 
hood health centers, and created 
the Division of Health Sciences and 
Technology. In 1 969, Ebert also 
founded Harvard Community Health 
Plan, the nation's first academic 
health maintenance organization. 





S P R I N G / S U M M E R 2007 • VOLUME 80, NUMBER 4 




DEPARTMENTS 



TRIBUTE TO JOSEPH MARTIN 



Strong Medicine 20 

Joseph Martin leaves a rich legacy at 
Harvard, hy George E. Thibault 

Leading by Listening 25 

what are the six essential quotients of 
gifted leadership? hy Joseph B. Martin 

Letters 3 

Pulse 5 

President's Report 1 1 

Transitions bring potential to the School 
and its alumni, by A. W.Karchmer 

Tlie Visible Hand 12 

A reviewer of research proposals finds an 
unexpected source of passion, hy Timothy Ferris 

Bookshelf 14 

Bookmark 15 

Benchmarks 16 

Alumna Profile 64 

Janet Regier hates the cold. Why, then, 
does she shuttle between the North and 
South Poles? hy]aniceO'Leary 

Class Notes 66 

Obituaries 69 

Endnotes 72 

The Class of 1968 staged a velvet 
revolution at Harvard Medical School. 



SPECIAL REPORT: DESIGN FOR HEALING 



Reform School 28 

After rolling out its first major curriculum reform in a generation. 
Harvard Medical School receives a report card, by rich barlow 

Object Lessons 36 

A first-year student navigates her way through a new curriculum and 
finds more promise than pitfalls, by ishani ganguli 

Holistic Learning 42 

An innovative clerkship immerses third years in clinical care, introducing 
them to medicine and, often, to themselves, by a-nn marie menting 

Sim City 48 

With their earhest patients made of silicon and circuitry, Harvard medical 
students are finding it easier to first do no harm. 

b^MARK BAARD 



The Vision of Music 54 

A physician who conducts music reflects on 
the healing powers of mingling the senses. 

by SAMUEL WONG 

Anatomy of a Doctor's Life 58 

Harvard awarded its first medical degree, 

an honorary one, to a colorful Salem physician. 

b;' ANTHONY S. PATTON 

Cover photograph: Katherine Lambert 




Harvard Merlir^l 



ALUMNI BULLETIN 



In This Issue 

HS I WRITE, OUR SISTER INSTITUTION THE LAW SCHOOL IS DEMOLISHING 
a pleasant modernist parking garage, which will be replaced with a 
larger postmodernist classroom buUding. In its time, the parking 
garage supplanted an amiable row of Victorian brick houses. Meanwhile, the 
Medical School is now in the terminal phase of replacing its latest, rather 
likable, curriculum with a new edifice of knowledge, practice, and inquiry. 

What I have found unnerving about the events at both schools is that I can 
clearly recall what came before the structures, architectural or curricular, that 
are now being replaced, and for a while I was an active participant in the latter. 
Where is Harvard's stuffy conservatism when you reach an age at which you 
might find it consoling? Granted the Quad is still standing and is unlikely to be 
replaced by anything more adapted to modern needs, and some of the School's 
faculty members appear nearly as indestructible. Yet at times like this we are 
reminded how much innovation there is at HMS, and that several innovations 
in succession may fit quite handily into a single living memory. 

Apart from the fact that it induces one to view oneself historically, the latest 
set of changes appears to be good for students, who all too soon will find them- 
selves on the slippery slopes of social and economic change as they try to live 
up to their concepts of excellence. Coping with the institutional context of 
medicine has become devHishly challenging and sometimes disheartening. 
What we can hope for from the new curriculum is that students will leave it 
not only with a better understanding of the institutions that provide care but 
also with the ideals and energy to begin tearing them apart and rebuilding 
them in ways that are sufficiently radical to be worthwhile. 

In this spirit, and this issue, we inaugurate a department that we call "The 
Visible Hand," a column about the political and economic context that shapes 
medicine in the United States. Our first columnist is Timothy Ferris '92, who 
takes on a topic that is fundamental to academic medicine: how the government 
solicits and reviews research proposals. Tim is a member of our Editorial Board; 
in one of his day jobs he studies the ways in which quahty of care can be mea- 
sured and enhanced. 



J,U^. 



\ IM 




EDITOR-IN-CHIEF 

WiUiam Ira Bennett '68 

EDITOR 

Paula Brewer Byron 

ASSOCIATE EDITOR 

Ann Marie Menting 

ASSISTANT EDITOR 

Janice O'Leary 

BOOK REVIEW EDITOR 

Elissa Ely '88 



EDITORIAL BOARD 

Judy Ann Bigby '78 

Rafael Campo '92 

Elissa Ely '88 

Daniel D. Federman '53 

Timothy G. Ferris '92 

Alice Flaherty '94 

Atul Gawande '94 

Robert M. Goldwyn '56 

Petri Klass '86 

Victoria McEvoy '75 

James J. O'ConneU '82 

Nancy E. Oriol '79 

Anthony S. Patton '58 

Mitchell T Rabkin '55 

Jason Sanders '08 

Eleanor Shore '55 



DESIGN DIRECTOR 

Laura McFadden 



ASSOCIATION OFFICERS 

A. W. Karchmer '64, president 

WiUiam W. Chin '72, president-elect 1 

Steven E. Weinbeigei '73, president-elect 2 

Susan M. Okie '78, vice president 

Rodney J. Taylor '95, secretary 
Douglas G. KeUing '72, treasurer 

COUNCILLORS 

Rosa M. Crum '85 

Wesley A. Curry '76 

Timothy G. Ferris '92 

Edward D. Harris, Jr. '62 

Lisa L lezzoni '84 

Triste N. Lieteau '98 

Christopher J. O'Donnell '87 

Rachel G. Rosovsky '00 

John D. Stoeckle '47 

DIRECTOR OF ALUMNI RELATIONS 

George E. Thibault '69 

EXECUTIVE DIRECTOR OF 
ALUMNI RELATIONS 

Mary Moran Perry 

REPRESENTATIVES TO THE 
HARVARD ALUMNI ASSOCIATION 

John D. Stoeckle '47 
Joseph K. Hurd, Jr. '64 

The Harvard Medical Alumni Bulletin is 

published quarterly at 25 Shattuck Street, 

Boston, MA 02115 * by the Harvard 

Medical Alumni Association. 

Phone: (617) 384-8900 • Fax: (617) 384-8901 

Email: bulletin@hms.harvard.edu 

Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



SECOND OPINIONS FROM OUR READERS | 



TETTERS^ 



GRACE AND FAVOR 

Special thanks to the Bulletin for the 
wonderful report, Sparks of Inspiration, in 
the Autumn 2006 issue. I enjoyed all seven 
articles and was particularly struck by the fact 
that three of them were about HMS alumni — 
Jim Kim '91, Ernest Darkoh '98, and Catherine 
Wilfert '62 — ^who have devoted themselves to 
bringing health care to some of the world's 
most neglected people. While it is well known 
that many HMS graduates do outstanding labo- 
ratory and clinical research, I found it particu- 
larly inspiring to learn about some who have 
made outstanding achievements in bringing the products of medical advances 
to needy populations around the world. Because of their brilhance, courage, 
and persistence, aU seven of the people profiled are truly heroic. 

CAVIN p. LEEMAN '59 
NEW YORK, NEW YORK 



HaT-vard Medical 


^ 


^Brksof 


^ 


INSPIRATION 

^-n -j.iniciif the 


tW ■sudden insij^hr- 
die ptiMin.il los-^.-^, 
ort!u-t:li.i]leni;i:sri> 
rv_a\cJ\\iM.!uin— 
iliiit lu\\;is;niti.xl 





Guiding Light 

Thanks so much for your case histories of 
HMS alumni and faculty members who 
have been inspired and have carried that 
inspiration to create great deeds. I have 
long admired Ernest Darkoh '98, Judah 
Folkman '57, and Catherine Wilfert '62, 
and I wanted to add a personal comment 
to Dr. Wilfert's sketch. 

In the last analysis, we professors wiU 
be remembered not so much by our papers 
in the New England Journal of Medicine but by 
our "children" and "grandchildren," those 
whom we have trained and inspired. After 
devoting 19 years to HIV care, training, 
and research, I approached Cathy in 2000 
about working in Africa. She took me 
under her wing and helped me obtain ini- 
tial funding to implement a program to 
prevent mother-to-child-transmission of 
HIV in Malawi. That program has since 
become one of the largest in Africa. 

Using Cathy's philosophy of viewing 
the big picture and the details simultane- 
ously, doing hands-on work, starting 
small, and conducting research to get nec- 
essary answers, I have subsequently men- 
tored others — her "grandchildren" — in 
both South Africa and Malawi. Her 



indomitable spirit, fierce work ethic, and 
generosity are legendary. I am so fortunate 
to know her and to count her as a friend. 

CHARLES VAN DER HORST '78 
CHAPEL HILL, NORTH CAROLINA 

Glimmer of Hope 

I enjoyed your article in the Bulletin on 
Judah Folkman '57. I had known about 
his work on angiogenesis for a long time, 
but not its use in macular degeneration. I 
have been surprised at the number of 
people I know who have macular degen- 
eration. Several of my closest friends are 
blind because of it. I hope Dr. Eolkmaris 
discovery proves to be a real solution. 



ROWLAND FRENCH 
EASTPORT, MAINE 



43B 



Quiz Kid 

I was startled and dehghted to see the 
Endnotes quiz in the Autumn 2006 issue 
of the Bulletin, but I was dismayed by your 
failure to give it proper attribution. The 
fake quiz was authored by David Sachar 
'63, who eventually became the first Dr. 
Burrill B. Crohn Professor of Medicine at 
the Mount Sinai School of Medicine. 

David authored the quiz as a response 
to the pathophysiology faculty's propen- 



sity to greet arriving students with 
quizzes on the chairs in one of the audi- 
toriums. Young faculty members harassed 
medical students by trying out their 
newfound multiple -choice test-writing 
skills, often with mangled results. An 
astonishing number of the real tests 
were incomprehensible. 

This particular "examination" was dis- 
tributed on the chairs in one of the audi- 
toriums, not in Vanderbilt Hall, as the 
Bulletin stated. I know, because Henry 
Keutmarm '63 and I helped David distrib- 
ute it early one morning in the short win- 
dow between the opening and the filling 
of the room. The three of us were thrilled 
to find that many of our classmates actu- 
ally tried to take the exam and did not 
realize it was fake untH they had perused 
several questions. I have an original in 
hand (not yet for sale on eBay); it is dated 
January 14, 1961. The exam consisted of 
three single-spaced pages, and it was a 
dehghtful spoof from beginning to end. 

Your excerpt included some of the 
more interesting questions but omitted 
my personal favorites; 

Which of the following is least unlikely not 
to occur: 

a. The failure of choriocarcinoma to 
metastasize to an organ other than 
the lung 

b. Death of a fetus without either 
abortion nor hydatidtform change, 
but not without both 

c. Neither of the above 

Carcinoma in situ of the cervix develops into 
invasive carcinoma: 

a. Not usually never 

b. Never in all cases, but often in many 

c. Not necessarily always, but rarely 
inmost 

d. Usually, in rare cases especially 

e. Generally, but not invariably never 

I win be glad to share the entire exam- 
ination with anyone who wishes to con- 
tact me at lockshinm@hss.edu. 

MICHAEL D. LOCKSHIN '63 
NEW YORK, NEW YORK 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 




TETTERS 



SECOND OPINIONS FROM OUR READERS 



Shedding New Light 

One letter to the editor in the Autumn 
2006 issue of the Bulletin, titled "Through 
a Glass Darkly," prompted me to respond. 
The photo of a man looking through a 
microscope is not a joke. In those days 
(and hkely today, as well) the micro- 



A TALE OF TWO CITATIONS 



scope was turned as shown in the photo 
whenever one looked at objects under 
very low magnification to make it easier 
to maneuver a slide, such as one with a 
Paramecium in a culture solution. The 
man in the photo seems to be looking at 
a raised object rather than at a standard 
slide and is obviously not using high- 



In a New York Times essay last December, Lisa Sanders credited Charles Dickens with 
the original description of what C. Sidney Burwell '19 and colleagues called alveolar 
hypoventilation, or Pickwickian syndrome, in a 1956 issue of the American Journal of 
Medicine. The essay reminded me of an article you ran in the Spring 2004 issue of the 
Bulletin about the Pickwickian syndrome, named for a grossly obese and somnolent 
boy, Joe, who fell asleep while knocking on a door in Dickens's The Pickwick Papers. 

Burwell was a former dean of Harvard Medical School. He and his associates had 
been unable to find any earlier description than that by Dickens and credited H. O. 
Sieker, et al., with prior scientific investigation of four cases. Yet John Fothergill, a 
famous London physician, reported similar cases of 

extreme obesity and disabling somnolence in two 
young people, a man and a woman, in a 1776 
edition of Medical Observations and Inquiries 
by a Society of Physicians in London. 
How did Burwell and his col- 
leagues miss Fothergill's paper? 
Medical papers are usually cat- 
alogued by title. For his title, 
Fothergill chose "Case 
of Angina Pectoris, with 
Remarks." The second half 
of this paper is the report 
of his two obese, somno- 
lent patients. Only some- 
one interested in early 
publications on angina 
pectoris — or an admirer of 
Fothergill — ^would have 
been likely to have discov- 
ered the second half of 
Fothergill's paper. Fothergill 
was a modest man and would 
not have protested the oversight. 
It is unlikely that Dickens was 
aware of Fothergill's report. 

WILLIAM L. PROUDFIT '39 
CLEVELAND, OHIO 




power magnification. He also has his 
hand near the hght source to change its 
intensity or reflection angle. My 
answer, then, to the query "Is this a real 
photo or a poorly contrived picture?" is 
that it's a true presentation of a knowl- 
edgeable observer using an old-style 
hght microscope correctly. 

ARNOLD A. LEAR '50 
POTOMAC, MARYLAND 

Name Dropping 

Now that I have completely retired, I 
have time to write to you about some- 
thing that has been bothering me for 
more than 60 years. 

I graduated from Harvard Medical 
School in 1944, on what should have been 
one of the happiest days of my life. It 
wasn't. First, my mother was sick and 
could not attend my graduation. My 
father had died in 1938. My graduating 
class marched in as privates and marched 
out as first lieutenants. I never had a 
chance to wear the cap and gown of a 
graduate of Harvard Medical School. We 
didn't even take the Hippocratic oath. 

And then came my biggest disappoint- 
ment. I received my diploma and found it 
was made out for Milton Philippum Shoob. 
Why did HMS have to Latinize my mid- 
dle name? I should have taken care of this 
error immediately, but I was in a hurry to 
leave and start my internship. I do not 
use my first name, just my first initial. 
But there was no way I was going to 
write a prescription for a patient and 
sign it M. Phihppum Shoob, MD. 

When I opened my office I hung my 
diploma in a conspicuous place so every- 
one would know I was a Harvard gradu- 
ate. Do you have any idea how many 
times I had to answer, "What's with the 
Phihppum?" I know it is much too late to 
do anything about this matter but I did 
have to get it off my chest. 

M. PHILIP SHOOB '44 
COMMACK, NEVi' YORK 

Editor's note: This spring, 63 years after 
his graduation, M. Phihp Shoob received 
a new, corrected diploma from HMS. 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



MAKING THE ROUNDS AT HMS 



PTIT.SE 



Under the Skylight 



■■■■■■ H£N JEFFREY FLIER MULLED 

^%^nfl a job offer from Harvard 
^\lj Medical School nearly 30 
^HH^H years ago, friends and col- 
leagues weighed in: Don't do it, they said. 
No one ever gets promoted there. 

Flier's career has laid these concerns 
to rest. He rose from chief of the Dia- 
betes Unit at what is now Beth Israel 
Deaconess Medical Center to head of 
the Endocrine Division to chief academ- 
ic officer and endowed professor at 
HMS, a trajectory that has recently cul- 
minated in his appointment as dean of 
the faculty of medicine. When he is offi- 
cially inducted in September, Flier will 
be the School's twenty-first dean. 

He succeeds Joseph Martin, who 
stepped down as dean at the end of 
June, after a decade of distinguished ser- 
vice at the School. 

"During the 29 years that I have pur- 
sued an extraordinarily rewarding aca- 
demic life within the Harvard medical 
community," Flier says, "I have come to 
know its amazing strengths from its 
students to its faculty, both on the 
Quad and within the Harvard-affiliated 
hospitals and research institutions. 

"This medical school is a national 
treasure," he says, "and while it is a 
humbling thought that I will now have 
great responsibility for maintaining and 
enhancing the accomplishments of 
HMS, this is a responsibility I accept 
with great optimism and excitement." 

Harvard University's new president. 
Drew Gilpin Faust, has praised Fher for 
being a progressive leader, an outstand- 
ing medical educator, and an eminent sci- 
entific investigator. 

As an endocrinologist and one of the 
nation's leading authorities on obesity 
and diabetes, Fher has researched the 
molecular mechanisms of insulin action 
and of insulin resistance in human dis- 
ease. His laboratory was one of the first 
to untangle why, in a typical population 
of obese animals, high levels of the hor- 




BIG MAN ON CAMPUS: Jeffrey Flier, the George C. Reisman Professor of Medicine at 
HMS, has been named the t^venty-first dean of Harvard Medical School. 



mone leptin were present. This didn't 
jibe with the conventional wisdom of the 
time, which held that leptiris function 
was to prevent obesity. But Fher consid- 
ered the possibihty of leptin resistance 
and demonstrated that the physiological 



role of leptin was not to prevent obesity, 
but to signal to the brain that there was 
an inadequate supply of energy, trigger- 
ing overeating and, potentially, obesity. 

Flier's discovery that leptin can 
switch the brain from a fed to a starved 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



pttt.sk 



MAKING THE ROUNDS AT HMS 



Harvard president Drew Gilpin Faust has praised Flier 
for being a progressive leader, an outstanding medical 
educator, and an eminent scientific investigator. 



state led to a fundamental reshaping of 
the discourse on diabetes and obesity. 

The author of more than 200 scholarly 
papers, FHer lately has focused on neu- 
roendocrine disease, the physiologic 
mechanisms by which signals throughout 
the body communicate to the brain, and 
the ways in which the brain exerts influ- 
ence over peripheral metabohc events. 
One recent paper examined the role of 
chemokines in recruiting macrophages, 
which have been imphcated in the patho- 
genesis of tnsuhn resistance, into fat cells. 

Fher entered the field of metabohc dis- 
eases early on. After earning his medical 
degree from Mount Sinai School of Medi- 
cine and doing his residency in internal 
medicine at Mount Sinai Hospital, he 
spent four years as a clinical associate at 



the diabetes branch of the National Insti- 
tutes of Health and the National Institute 
of Arthritis, Metabohsm, and Digestive 
Diseases before joining HMS in 1978. 

He was promoted to fuU professor in 
1993 and named the George C. Reisman 
Professor of Medicine in 1998. In 2002, 
Fher was named chief academic officer at 
Beth Israel Deaconess Medical Center, a 
senior position responsible for research 
and academic programs. There he worked 
with the academic department chairs to 
ensure quahty and breadth in the center's 
academic programs, through which most 
Harvard medical students pass. He also 
served as the formal haison to the School, 
sitting on the Council of Academic Deans. 

Fher has most recently been active in 
shaping medical education through his 



stewardship of HMS teaching programs 
at Beth Israel Deaconess Medical Center 
and his involvement with the curriculum 
committee for the Harvard-MIT Health 
Sciences and Technology program. 

Flier has also been closely involved in 
recent discussions of the future of Har- 
vard-wide science as a founding member 
of the Harvard University Science and 
Engineering Committee and through his 
service on the University Planning Com- 
mittee for Science and Engineering. 

"This is an exciting time for Harvard 
medicine," says Harvard University Provost 
Steven Hyman '80, "as transformative 
developments in biomedical research 
greatly expand our opportunities to 
understand disease and improve human 
health. At such a moment, we are very 
fortunate to have someone with Jeff 
Fher's broad leadership experience in 
medical research and education, deep 
familiarity with Harvard, and strong 
sense of future possibihties to help Har- 
vard Medical School rise to the chal- 
lenges ahead." ■ 




Route '66 



BARBARA MCNEIL BECAME ACTING DEAN 

of Harvard Medical School on July 1 . 
McNeil, a member of the Class of 1966, 
is the Ridley Watts Professor of Health 
Care Policy at HMS, chair of the School's 
Department of Health Care Policy, and 
HMS professor of radiology at Brigham 
and Women's Hospital. 

"Barbara has a proven track record as 
a leader in our medical community," says 
Joseph Martin, who recently stepped 
down after a decade as dean of the 
School. "HMS is fortunate to be able to 
turn to her in this time of transition." 

Under McNeil's stewardship, the 
Department of Health Care Policy has 



become a national leader in health ser- 
vices research and in the scholarly areas 
on the boundary between clinical medi- 
cine and behavioral science. McNeil has 
earned national and international recog- 
nition for her seminal work bringing the 
methods of decision science and technol- 
ogy assessment into the health care 
arena. She is also renowned for her aca- 
demic contributions describing the rela- 
tionships among clinical services, quality 
of care, and patient outcomes. 

"Harvard Medical School is an excep- 
tional institution and has made tremendous 
contributions in research and education — 
and, with its teaching hospitals, in patient 
care as well," says McNeil. "I am pleased 
to serve in this period of transition." ■ 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



Win, Place, Show 

Once again, Harvard Medical School was 
the horse to bet on in the race for number 
one in U.S. News & World Report's annual 
hsting of the nation's exceptional gradu- 
ate schools, garnering an overall perfect 
score and placing first among the coun- 
try's medical schools in the research cat- 
egory. HMS also earned top marks in 
women's health; second place in the 
fields of AIDS, pediatrics, and internal 
medicine; and third place in drug and 
alcohol abuse treatment. 



Budding Endeavor 



Pulling Rank 



Harvard- affihated hospitals have again 
placed high in U.S. News & World Rcporfs 
annual rankings of the nation's nearly 
5,500 medical centers. Of the 173 hospitals 
that made it into the rankings, 18 scored 
high in at least six specialties, qualifying 
for honor-roll status. Of those star achiev- 
ers, Massachusetts General Hospital 
ranked fifth and Brigham and Women's 
Hospital tenth. 

Harvard hospitals also received recog- 
nition for outstanding work in 16 special- 
ties. Massachusetts General Hospital's 
rankings included first in psychiatry; sec- 
ond in endocrinology; third in orthope- 
dics; fourth in digestive disorders, geri- 
atrics, kidney disease, neurology and 
neurosurgery, and respiratory diseases; 
fifth in heart and heart surgery; seventh 
in rheumatology; tenth in cancer; and 
eleventh in urology. 

Brigham and Women's Hospital rank- 
ings included first in kidney disease; sec- 
ond in gynecology; third in heart and heart 
surgery; sixth in rheumatology; ninth in 
endocrinology; tenth in digestive disor- 
ders; and eleventh in orthopedics. Among 
other Harvard-affihates, Beth Israel Dea- 
coness Medical Center's placements 
included tenth in geriatrics; twelfth, with 
the Joslin Clinic, in endocrinology; and 
fourteenth in digestive disorders. 

Other Harvard hospitals in the place- 
ments included McLean Hospital, 
ranked third in psychiatry; Massachu- 



A NEW DEPARTMENT HAS BEEN FORMED AT HARVARD, THE FIRST ACADEMIC 

department in the institution's 371-year history to be based in more than one of 
the University's schools. The Department of Developmental and Regenerative Biol- 
ogy will splice researchers from Harvard Medical School and the Faculty of Arts 
and Sciences (FAS) to take advantage of opportunities in multidisciplinary areas 
of science and engineering. 

"Over the past decade the School has developed many strong collaborations 
with our hospitals and with 
other Harvard faculties," says 
Joseph Martin, who recently 
stepped down as dean of HMS. 
"But this new initiative, with its sta- 
tus as a full-fledged department, 
will have academic opportunities 
that are unprecedented in terms of 
appointments and the options for 
creating learning opportunities." 
The department will be housed in 
Harvard's new science complex 
in Allston, which is slated for com- 
pletion in two years. 

To integrate the often disparate 
bodies of scientific research with- 
in FAS, HMS, and the School's 

affiliated hospitals, the department will have two chairs — David Scadden, the 
HMS Gerald and Darlene Jordan Professor of Medicine at Massachusetts General 
Hospital, and Doug Melton, the Cabot Professor of the Natural Sciences in FAS. 
Scadden and Melton, founding co-directors of the Harvard Stem Cell Institute, 
stress that the new academic department will complement and strengthen, rather 
than supplant, that institute. 

"Creating this department clearly signals that Harvard is going to be bold and 
is going to lead in forging new connections between basic science and human 
health," says Scadden. "It will create exciting and unique educational opportuni- 
ties for our students at all levels by bringing these worlds together. Placing it in 
Allston will create an organizing hub to bring together the medical and Cambridge 
campuses. It is an experiment. If successful, it may transform the University." ■ 




setts Eye and Ear Infirmary at fourth for 
both ophthalmology and ear, nose, and 
throat; Dana-Farber Cancer Institute, 
ranked fifth in cancer; and Spaulding 
Rehabilitation Hospital, ranked eighth in 
rehabilitation medicine. Children's Hos- 
pital, which has placed first or second in 
pediatrics for the past 17 years running, 
has not yet received its ranking, as U.S. 
News & World Report is revamping its 
guidelines for pediatrics. 



Sin Rewarded 

The Bulletin recently received two national 
awards from the Council for Advancement 
and Support of Education, or CASE: a 
grand gold medal for its special report on 
the seven deadly sins, and a silver medal in 
the special constituency magazines cate- 
gory. The Bulletin also won a Clarion Award 
in the category of Best Overall External 
Magazine, Circulation of 100,000 or less. ■ 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ptit.se 



MAKING THE ROUNDS AT HMS 



Near Landings 



ON THE 55TH ANNUAL MATCH DAY, 180 HMS STUDENTS TORE OPEN THEIR ENVELOPES AND 

learned where they would be spending their residencies. More than half of the HMS 
grads will remain in Massachusetts. Seven percent of the class will head for New 
York City and 18 percent 
for cities in California. The 
most popular specialty is 
internal medicine, followed 
by pediatrics and emer- 
gency medicine. Specialties 
that saw an increase in the 
number of matches com- 
pared to last year include 
anesthesiology, radiology, 
and neurology, while pedi- 
atrics, emergency medicine, 
and family practice each 
had decreases. 




ANESTHESIOLOGY 

Raul Calderon 

UCLA Medical Center 

Daphney Frederique 

New England Medical Center 

Patricia Garcia 

Brighom end Women's Hospital 

Robert Griffin 

Massachusetts General Hospital 

Vanessa Henke 

Massachusetts General Hospital 

Payal Kohli 

Massachusetts General Hospital 

Choy Le>vis 

Brigham and Women's Hospital 

Aurora Quaye 

Massachusetts General Hospital 

James Rhee 

Massachusetts General Hospital 

Russell Roberson 

Duke University Medical Center 

DERMATOLOGY 

Heidi Goodarzi 

University of California- 
Davis Medical Center 

Rita Khodosh 

Stanford University Programs 



Arash Mostaghimi 

Massachusetts General Hospital 

Haley Naik 

Massachusetts General Hospital 

Alexis Perkins 

University of Massachusetts 
Medical School 

EMERGENCY MEDLCINE 

Steven Bailey 

Alameda County Medical 
Center, Oakland, CA 

Roberta Capp 

Brigham and Women's Hospital 

Halcyeane Dardaine 

Temple University Hospital, 
Philadelphia 

Moses Graubard 

Harbor-UCLA Medical Center, 
Torrance, CA 

Caitlin Higgins 

Alameda County Medical 
Center, Oakland, CA 

Nathan Irvin 

Alameda County Medical 
Center, Oakland, CA 

Katherine Kimbreil 

Rhode Island Hospital/Brown 
University, Providence 



Poojar Kumar 

Brigham and Women's Hospital 

Maria Nemethy 

St. Luke's-Roosevelt Hospital, 
New York City 

Mario Ramirez 

Vanderbilt University 
Medical Center, Nashville 

Hector Rivera 

Yale-New Haven Hospital 

Louis Rivera 

Beth Israel Medical Center, 
New York City 

Jonathan Thiermon 

Johns Hopkins Hospital 

Jonathan Welch 

Brigham and Women's Hospital 

FAMILY PRACTICE 

Elizabeth Ferrenz 

University of California- 
San Francisco 

Alisha Kithcart 

Cambridge Hospital, 
Cambridge, Massachusetts 

Michael Monge 

Ventura County Medical 
Center, Ventura, CA 



INTERNAL MEDICINE 

Andrew Aguirre 

Massachusetts General Hospital 

Rima Arnoout 

Massachusetts General Hospital 

Jakob Begun 

Brigham and Women's Hospital 

P. Alexandra Binnie 

University of Toronto 

Erin Bohula 

Brigham and Women's Hospital 

Jorge Castellanos 

University of California- 
San Francisco 

Leticia Castillo 

University of Texas Southwestern 
Medical School, Dallas 

Eugene Chan 

Brigham and Women's Hospital 

John Chorba 

Massachusetts General Hospital 

Bradley Crotty 

Beth Israel Deaconess 
Medical Center 

Phillip Erwin 

Massachusetts General Hospital 

Gregg Furie 

Hospital of the University of 
Pennsylvania, Philadelphia 

Manish Gala 

Stanford University Programs 

Lauren Goldstein 

New York Presbyterian 
Hospital-Columbia 

Lipika Goyal 

Brigham and Women's Hospital 

Robert Hagan 

Johns Hopkins Hospital 

John Hinson 

Massachusetts General Hospital 

Guibenson Hyppolite 

Massachusetts General Hospital 

MituI Kadokia 

Brigham and Women's Hospital 

Vanessa Kerry 

Massachusetts General Hospital 

Gyanprakosh Ketwaroo 

Massachusetts General Hospital 

Alicia Mecklai 

New York Presbyterian 
Hospital— Columbia 



8 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



Heather Morris 

New York Presbyterian 
Hospital-Columbia 

Sheila Naghshineh 

UCLA Medical Center 

Kim-Son Nguyen 

Beth Israel Deaconess 
Medical Center 

Sahar Nissim 

Brigham and Women's Hospital 

Folasade Popoola 

Massachusetts General Hospital 

Lynn Punnoose 

Brigham and Women's Hospital 

Ruma Rajbhandari 

Brigham and Women's Hospital 

Alaka Ray 

Massachusetts General Hospital 

Douglas Rubinson 

Brigham and Women's Hospital 

Bharat Somy 

Brigham and Women's Hospital 

Erica Seiguer 

Massachusetts General Hospital 

Jennifer Stevens 

Brigham and Women's Hospital 

John Szumov/ski 

Beth Israel Deaconess 
Medical Center 

David Takeda 

Brigham and Women's Hospital 

Viviany Taqueti 

Massachusetts General Hospital 

Vesselin Tomov 

Hospital of the University of 
Pennsylvania, Philadelphia 




Melissa Tukey 

Beth Israel Deaconess 
Medical Center 

Scott Vafai 

Brigham and Women's Hospital 

Jason Wasfy 

Massachusetts General Hospital 

Frederick Wilson 

Brigham and Women's Hospital 

Joseph Wright 

Beth Israel Deaconess 
Medical Center 

D. Ying Wu 

Yale-New Haven Hospital 

Anthony Yu 

Hospital of the University of 
Pennsylvania, Philadelphia 

Payman Zamoni 

Brigham and Women's Hospital 

INTERNAL MEDICINE/ 
PRIMARY CARE 

Eleanor Adams 

New York Presbyterian 
Hospital-Cornell 

Mary Berlik 

Massachusetts General Hospital 

Sarun Charumilind 

Massachusetts General Hospital 

Paul Cremer 

Massachusetts General Hospital 

Chevon Haswell 

University of Colifornia- 
San Francisco 

Risho Irby 

University of California- 
San Francisco 

Adrian Kenny 

Yale-New Haven Hospital 

Christine Pace 

Brigham and Women's Hospital 

Jennifer Siegel 

University of California- 
Son Francisco 

Andre>v Singer 

Brigham and Women's Hospital 

Benjamin Sommers 

Brigham and Women's Hospital 

Jeanie Yoon 

University of Washington 
Affiliated Hospitals, Seattle 



NEUROLOGY 

Martinson Arnan 

Johns Hopkins Hospital 

Riley Bove 

Massachusetts General Hospital 

Ashutosh Jadhav 

Massachusetts General Hospital 

Susanna Mierou 

Massachusetts General Hospital 

Bradley Molyneaux 

Massachusetts General Hospital 

Neelaksh Varshney 

Massachusetts General Hospital 

OB/GYN 

Tara Benjamin 

Tulane University School of 
Medicine, New Orleans 

Carolyn Casey 

University of California- 
San Francisco 

Somor Hassouneh 

University of Michigan 
Hospitals, Ann Arbor 

Andrea Jackson 

Brigham and Women's Hospital 

Tiffany Jackson 

Brigham and Women's Hospital 

OPHTHALMOLOGY 

Jason Brinton 

University of Iowa, Iowa City 

Ani Khondkaryan 

University of Southern 
California, Los Angeles 

Apurva Patel 

Scheie Eye Institute, Philadelphia 

ORAL AND MAXILLO- 
FACIAL SURGERY 

Salim Afshor 

Massachusetts General Hospital 

ORTHOPEDIC SURGERY 

Luis Corrales 

University of California- 
San Francisco 

AtuI Kamoth 

Hospital of the University of 
Pennsylvania, Philadelphia 



Adam Kaufman 

Duke University Medical Center 

Sang Kim 

Massachusetts General Hospital 

Conor Klev/eno 

Massachusetts General Hospital 

William Lack 

University of Iowa Hospitals 
and Clinics, Iowa City 

Dennis Meredith 

Hospital for Special Surgery, 
New York City 

Konu Okike 

Massachusetts General Hospital 

James Ross 

Barnes-Jewish Hospital, St. Louis 

Scott Thompson 

New York Presbyterian 
Hospital-Columbia 

OTOLARYNGOLOGY 

David Jung 

Massachusetts Eye & Ear Infirmary 

Matthew Keller 

Naval Medical Center, 
San Diego 

Mina Le 

University of Minnesota 
Medical School 

Megan McLellan 

AAassochusetts Eye & Ear Infirmary 

Barbar Sultan 

Johns Hopkins Hospital 

PATHOLOGY 

Sophie Currier 

Massachusetts General Hospital 

Ricky Grisson 

Massachusetts General Hospital 

Ji Yeon Kim 

Massachusetts General Hospital 

PEDIATRICS 

Nicole Boumer 

Massachusetts General Hospital/ 
Children's Hospital Boston 

Grace Chan 

Children's Hospital Boston 

John Flibotte 

Children's Hospital of Philadelphia 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



pttt.se 



MAKING THE ROUNDS AT HMS 



Lindsay Freud 

Children's Hospital Boston 

Efren Gutierrez 

Massachusetts General Hospital 

Matthew Kelly 

Children's Hospital Boston 

Matthe>v Lewis 

Brigham and Women's Hospital 

Elizabeth Morrison 

University of California- 
San Francisco 

Yana Pikman 

Children's Hospital Boston 

Lindsay Pindyck 

Massachusetts General Hospital 

Jenny Radesky 

University of Washington 
Affiliated Hospitals, Seattle 

Christopher Russell 

University of California- 
San Francisco 

Ashaunta Tumblin 

Baylor College of Medicine 

Jennifer Woo 

Children's Hospital Los Angeles 




Allison Young 

University of Washington 
Affiliated Hospitals, Seattle 

PEDIATRICS/ 
PRIMARY CARE 

Michael Tang 

Children's Hospital Boston 

PHYSICAL MEDICINE/ 
REHABILITATION 

Cindy Lin 

Stanford University Programs 

PLASTIC SURGERY 

Sylvia Aparicio Gray 

University of Texas Medical 
Branch, Galveston 

Ryan Gerry 

Brigham and Women's Hospital 

Anne Warren 

University of California- 
San Francisco 

PSYCHIATRY 

Rebecca Aspden 

Hospital of the University of 
Pennsylvania, Philadelphia 

David Cochran 

University of Massachusetts 
Medical School 

Annalise Keen 

Cambridge Hospital 

Rebecca Levels 

New York University 
School of Medicine 

Andrew Rosenfeld 

New York Presbyterian 
Hospital-Columbia 

David Soskin 

University of California- 
San Francisco 

Lisa Zakhory 

Massachusetts General Hospital 

RADIATION ONCOLOGY 

Nils Arvold 

Brigham and Women's Hospital 

Jona Hattongadi 

Brigham and Women's Hospital 



Benjamin King 

University of Washington 
Affiliated Hospitals, Seattle 

Stephanie Krejcorek 

Brigham and Women's Hospital 

John Ng 

New York Presbyterian 
Hospital-Columbia 

RADIOLOGY 

Donnie Bell 

Brigham and Women's Hospital 

Donnette Dabydeen 

Brigham and Women's Hospital 

Jean-Marc Gauguet 

Beth Israel Deaconess 
Medical Center 

Marc Laberge 

University of California- 
San Francisco" 

Ryan Lokken 

Brigham and Women's Hospital 

Michael Lu 

University of California- 
San Francisco 

Laura Nason 

University of Washington 
Affiliated Hospitals, Seattle 

Michael Ohiiger 

University of California- 
San Francisco 

Christopher Selhorst 

Brigham and Women's Hospital 

Jennifer Son 

Beth Israel Deaconess 
Medical Center 

Anna Szary 

University of California- 
San Francisco 

Ernest Yeh 

Beth Israel Deaconess 
Medical Center 

SURGERY 

Sarah Abbett 

Brigham and Women's Hospital 

Mabel Chung 

New York University School of 
Medicine 

Yun-Sheen Liu 

Brigham and Women's Hospital 



Edgar Macias 

University of California- 
San Francisco 

Ankit Mehta 

Brigham and Women's Hospital 

Luise Pernor 

Brigham and Women's Hospital 

Daniel Steinhous 

University of California- 
San Francisco 

Alisso Weinberg 

Brigham and Women's Hospital 

Richelle Williams 

University of Chicago Medical 
Center, Chicago 

UROLOGY 

Eugene Cho 

New York Presbyterian 
Hospital-Cornell 

Joirom Eswora 

Massachusetts General Hospital 

Sarah Psutko 

Massachusetts General Hospital 

OTHER 

Irene Chen 

Bauer Fellow, Harvard University 

Paul Anthony Crowley 

Admissions Officer, MIT 

Diarro Lamar 

Associate, McKinsey & Co., 
Florham Park, New Jersey 

Roxonne Londesman 

National Naval Medical 
Center, Bethesda, Maryland 

Andrev/ Levin 

Genzyme Corporation, 
Cambridge, Massachusetts 

Craig May 

Research, Boston 

Joshua Nassiri 

Naval Medical Center, San Diego 

Sofa Sadeghpour 

Associate, McKinsey & Co., 
mid-Atlantic office 

Jay Shendure 

Research 

Griffin Weber 

Chief Technology Officer and 
Instructor in Medicine, HMS/Beth 
Israel Deaconess Medical Center 



10 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



PRF.STDENT^S REPORT 



Agents of Change 




HE PAST YEAR HAS BEEN ONE OF CONTINUING TRANSITION 

at Harvard Medical School. The most momentous 
change was Joseph Martin's stepping down as dean 
after leading the School through ten years of remark- 
able, multidimensional growth. In June, I heard Joe describe 
essential quotients for effective leadership, including intelli- 
gence, empathy, humor, optimism, generosity, and wisdom. On 
Alumni Day, I had the pleasure of thanking Joe for the apphca- 
tion of those quotients in his own leadership, for his guidance of 
the School, and for his warm embrace of HMS alumni. 

This past year also marked the launch of the School's long- 
awaited, carefully crafted new curriculum under the leader- 
ship of Jules Dienstag, the dean for medical education at 
HMS. The changes, which promise more structure and conti- 
nuity of contact between students and faculty in the clinical 
years, have already generated enthusiastic responses. 



William Chin '72 and Steven Weinberger '73, the Council's 
incoming president and president-elect, respectively, wtR work 
to link alumni to the School, to one another, and to students who 
have expressed an interest in alumni as mentors. We encourage 
all alumni to take part in our new virtual community by visiting 
www.hms.harvard.edu/alumni and cKcking on post.harvard. 

Transition is also under way at the Alumni Fund. Daniel 
Federman '53, who has been serving as the fund's interim 
chair, has reassessed the fund's goals and operation and the 
role of class agents. His report to the Council cited the needs 
for increased fundraising to keep pace with efforts to allay 
student debt, a greater professionalization of the fund's 
administration, and the estabhshment of renewable terms for 
class agents rather than a continued rehance on the current 
lifelong ones attached to these demanding positions. A com- 
mittee has begun the search for a permanent director of the 




Service on the Council has reinforced my appreciation 
of the uniqueness of HMS, the talents of its faculty 
and students, and the wisdom of its alumni. 



The Alumni Council has undergone changes of its own. 
During the past several years, it has evolved into a fully 
engaged committee actively seeking to strengthen the School 
and benefit its alumni and students. With Joe's encourage- 
ment, for example, we took on the problem of student debt. 
We facihtated an increase in the family income cutoff below 
which parental contributions to tuition are not required. The 
increased number of alumni donating to the Alumni Fund has 
enabled the School to sustain this cutoff. The Council remains 
committed to easing the burden of student debt. 

After extensive discussions with Sanjiv Chopra, faculty 
dean for continuing education, the Council voted to establish 
automatic membership for all alumni in the HMS Postgradu- 
ate Medical Association. This membership will extend such 
benefits as access to online offerings and other curricular con- 
tent of the School's continuing medical education program, as 
well as invitations to regional Pri-Med courses. Harvard's 
continuing education program for primary care physicians. A 
future issue of the Bulletin vnR provide details. 

The Council has supported the integration of an electronic 
alumni directory with our new Alumni Association website. 



fund. Chaired by George Thibault '69, director of alumni rela- 
tions, the committee includes Dan Federman; Bill Chin; Mary 
Moran Perry, executive director of alumni relations; and me. 
Please send nominations to mary_perry@hms.harvard.edu. 

Another transition took place recently, one we all regret: 
Jean Hurd, who has guided so many HMS classes through the 
reunion planning process and has served the Council so faith- 
fully, has retired. We thank Jean for her superb service and 
wish her well. 

It has been my privilege and honor to serve as your presi- 
dent for the past year. Even though I've been a member of the 
HMS faculty for nearly four decades, service on the Council 
has rekindled my relationship to the School and has rein- 
forced my appreciation of the uniqueness of HMS, the talents 
of its faculty and students, and the wisdom of its alumni. 

The Council is committed to serving the interests of the 
School and its students and alumni. Let us hear from you. ■ 

A. W. Karchmcr '64 is HMS professor of medicine and chief of the Division 
of Infectious Disease at the Beth Israel Deaconess Medical Center in 
Boston. Re can he reached at akarchme@hidmcharMard.edu. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 11 



THE VTSTR T.E HAND 



I HEALTH CARE POLICY AT WORK 



The Paper Trail 




S I TOOK AN AISLE SEAT ON THE WASHINGTON, DC-BOUND 

plane, I glanced at the man seated by the window. 
His disheveled clothes ruled out lobbyist, and his 
tired eyes suggested he had been laboring through 
the papers stacked on the seat between us. But the heavily 
marked'up pages in his hand gave him away. 

A grant apphcation for the National Institutes of Health is 
unmistakable even from a distance: single-spaced text, half- 
inch margins, principal investigator's name in the upper right- 
hand corner of each page. Like me, my feUow traveler was 
headed to the capital to participate in a study section. I placed 
my own stack of apphcations on the seat next to his. He 
groaned and flashed me an empathetic smile. 

I was traveling to my final scientific review committee 
meeting after three years of service. Odd as it may seem, I have 
had few experiences that have created as much anxiety and, 
well, passion. 

Last year, through the NIH, the federal government dis- 
pensed $21 blUion in biomedical research grants. How does the 
nation decide what science and which scientists are worth 
funding? It works like this; The NIH determines what general 
areas of research show the most promise and issues requests 
for proposals or apphcations. Scientists then spend several 
months crafting documents that often run to 50 pages. 

In 2006, the NIH received more than 45,000 of these pro- 
posals. If stacked, those half-tnch-thick apphcations would 
exceed the height of what was untH recently the world's tallest 
buHdtng, which juts a third of a mile into the Taipei sky. Each 
must be reviewed. That's where my flying companion and I 
came in. He was headed to a study section for the National 
Heart, Lung, and Blood Institute; I was headed to the compar- 
atively small Agency for Healthcare Research and QuaUty. 
That same year, more than 1,500 study sections convened an 
estimated 18,000 scientists to review apphcations for federal 
funding. Study sections are assigned a topic area and typically 
meet several times a year for two or three days. 

Reaching for the Stars 

The bottom hne for any grant apphcation is the score, which 
ranges from 100 (perfect) to 500 (absurd). Although scores 
don't determine funding, they are critical. Every application is 
first reviewed and scored by at least three members of the 
study section and then by the group as a whole, which entails 
assessing the scientific worth of some of the densest and most 
specialized prose on the planet. This is not hght reading, and 
it's work that tends to get done on nights and weekends. My 
kids know when it is grant-review season and are not amused. 



Grant applications are highly structured sales pitches. 
Investigators need to prove they know the science that pre- 
ceded theirs — how they stand on the shoulders of giants — and 
persuade reviewers of the importance of their topic. To do this 
they may cite more than a hundred references (a good sales- 
person wouldn't want to miss citing a potential reviewer's 
work) and end with an autobiographical puff piece. 

The methods section provides a step-by-step walk through 
the experiments and their analyses. It can sometimes be tricky 
for the reviewers to figure out whether — to paraphrase Victor 
Hugo — the picture painted in this section is a view of the stars 
in heaven or just the radiations created by the impressions of a 
duck's foot pressed in mud. 

Strike Three 



My traveling companion and I employed a similar approach to 
scoring. After finishing our first reading, we would start at 
the end, the anticipated result, and work backward through 
the methods to locate logical flaws undermining the conclusion. 
The process was iterative; checking back and forth through the 
application to ensure that each assertion was vaUd, each step fol- 
lowed from the previous step, and each calculation was sound. 

Why the attention to detail? The simple — and official — 
answer is that every apphcation deserves a thorough review. 
But the reviewer also gets caught up in a social system that has 
the potential to unmask a scientist's most prized personal 
quahty; his or her intellect. 

Reviewers must justify their scores in front of all study sec- 
tion members. This face-to-face exchange is an essential aspect 
of the process. Giving an apphcation a poor score is like mak- 
ing a diagnosis of exclusion. You face three possibilities; you 
were half asleep and simply need to try again; the writing is 
unclear but the apphcation is fundamentally sound; or your 
impression of the apphcatioris limitations is correct. For each 
such grant you need to rule out the first two possibihties well 
enough to feel comfortable with reaching the third. At some 
point you must make your call. Like an umpire you call it as 
you see it — ^but you call it to a room fuU of umpires. 

Most apphcations have small flaws, and seasoned review- 
ers demonstrate their skills by finding mismatches between 
the budget and the methods, pointing out incorrect citations, 
or even detecting small errors in the statistical approach. 
Although these weaknesses may hurt an application's score, 
they are generally not significant. On the other hand, a 
reviewer does not want to be caught missing a "fatal flaw" — 
the informal term describing an error in logic or approach that 
fundamentally and irreparably invahdates that proposal. A 



12 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 




Hr 




scientist's failure to detect a fatal flaw is the equivalent of a 
physician's missed diagnosis. 

A Roadmap Less Traveled 

The process has hmitations, of course. First, the effort and cost 
it takes to recruit, manage, and sponsor a study section are 
substantial, even with electronic review, and having hundreds 
of senior scientists read through stacks of apphcations when 
only a few will be funded may not be the best use of their time. 
Second, problems of groupthink can arise in the meetings, 
favoring fairly conservative approaches over truly innovative 
work. Young scientists without track records may not get the 
same nod as estabhshed investigators with big reputations. 
Forceful personahties can sway the group (think J2 kngry Men). 
Moreover, some grants end up in the hands of the vvTong 
reviewers. Finally, not every reviewer pores over each detail 
the way my fellow traveler clearly had. 

NIH managers try to minimize these risks by carefully 
selecting and screening chairs and reviewers. The rules gov- 
erning conflicts and disclosures are strict and vigorously 
enforced. Nonetheless, as with any enterprise based on human 
interactions, problems — and mistakes — inevitably occur. 



Is this cumbersome but painstaking process the best way to 
decide how to fund science? The NIH Roadmap for Medical 
Research has already begun to modify it. Recognizing that cer- 
tain urgent questions, such as figuring out which genes are 
involved in cancer, are too pressing to be left to the market- 
place of ideas, the NIH is becoming more directive about what 
it wants to fund and about how the funding will be used. 
Study sections still review grant apphcations, but apphcants 
no longer have to justify the importance of the questions to be 
answered — NIH officials have akeady decided that. 

Yet the old, flawed process has produced extraordinary sci- 
entific wealth. A more "efficient" process, given the big bucks 
and high stakes, might be vulnerable to insidious and destruc- 
tive distortions. The more prescriptive approach contained in 
the NIH Roadmap may, for example, be more susceptible to 
pohtical winds. How we make choices about what science 
should be funded wih continue to evolve, and almost certain- 
ly no single best method exists. Winston Churchill's maxim 
about democracy might apply here; Study sections are the 
worst way to fund science, except for all the others. 

The Agony and the Ecstasy 

Looking through my stack of applications on the flight to 
Washington, I realized how important this experience has 
been to me. This was tough, often mind-numbing work, yet 
rich with reward: I encountered many new facts and ideas 
and developed a deep appreciation for the investigators who 
labored to produce the apphcations. And although my fellow 
reviewers and I didn't always agree, our meetings cemented 
relationships based on a shared passion — in our case, improv- 
ing the delivery of health care — and a shared willingness to 
bare our intellectual acumen to each other. For a scientist, 
that's a bit like taking your clothes off in pubhc. And I felt hum- 
bled by my colleagues' extraordinary displays of brainpower. 

In the end, though, the study-section process is about help- 
ing to move that one terrific grant, the one that wiU make a 
difference, to the front of the line. It is the wheel that 
advances science, that makes possible the discovery, for exam- 
ple, of the gene that controls insulin secretion or causes 
prostate cancer. During my tenure on a study section I was 
fortunate enough to review several truly extraordinary grants, 
and I am proud to have played a small part in their success. ■ 

Timothy Ferris '92 is an assistant professor of medicine and pediatrics at 
Harvard Medical School, medical director of the Massachusetts General 
Physicians Organization, and a senior scientist at the Institute for Health 
Policy at Massachusetts General Hospital 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 13 



ROOKSHET.F 



BOOKS BY OUR ALUMNI 




ATUL 
GAWANDE 

better 

I 



Impressive I 
Weight Loss, 



THE 
POWER 

OF THE BITE 




MINDFUL BRAIN 





fTre 




P 




[Kind 

A 


^ 


i 




|rPerr 


IvlasTT 


m!d 


ZL 









The Enemy 

By Rafael Campo '92 (Dufee Universit}' 
Press, 2007) 

In his fifth collection of poetry, Campo 
writes of a country endlessly at war, not 
only against evildoers abroad but also 
with its own troubled conscience. Love, 
hope, and transformation are persistent 
themes in these 49 poems, which range 
m. form from the IZ-syllable haiku to the 
line-repeating pantoum. 

Better 

A Swrgcoyi^ Tslotcs on Performance, by Atul 
Gawande '94 (Metropolitan Books, 2007) 



Gawande is concerned with perfor- 
mance, particularly wdth the gap between 
what doctors aspire to do and what they 
accomphsh — and how that gap might be 
closed. He finds his answers in the impor- 
tant human quahties of diUgence, moral 
clarity, and the capacity for change. He 
seeks lessons in the contrasts between 
practice and intention in battlefield 
tents, malpractice courtrooms, and even 
the contentious history of hand v^'ashing. 

The Power of the Bite 

Impressive Weight Loss, One Bite at a Time, 
by Michael A. Nierenberg '71 
(iUniverse, 2006) 



This quick read wiH inspire people who 
approach weight loss with low-cal inten- 
tions yet high-cal hors d'oeuvres. The 
author promotes Mestyle changes rather 



than dieting. Cut just 120 calories per day, 
he says, and lose four ounces per week, for 
a loss of more than 25 pounds over two 
years; add exercise and hasten the loss. He 
provides tricks to trim calories — such as 
replacing the oil at the top of a salad 
dressing bottle with balsamic vinegar — 
and charts to guide meal choices. 

Medical Management of Vulnerable 
and Underserved Patients 

Principles, Practice, and Populations, 
edited by Tahnadge E. King, Jr. '74 and 
Margaret B. Wheeler (McGraw-Hill 
Medical, 2007) 



Working with patients whose barriers to 
health care include a lack of insurance, 
inadequate access to transportation, or 
poor English language skills often 
requires physicians to take novel 
approaches. This book offers suggestions 
for navigating cross-cultural communi- 
cation, locating valuable community 
resources for patients, and promoting 
comphance. One tip, for example, recom- 
mends creating a visual, weeklong med- 
ication schedule for any patient who does 
not understand Enghsh well. 

The Mindful Brain 

Reflection and Attunement in the Cultivation 
of Well-Being, by Daniel J. Siegel '83 
(Norton, 2007) 



Siegel, a neurobiologist, discusses how 
being mindfully aware — fully present in 
the moment — not only keeps us atten- 
tive to the richness of our experiences 



but also leads to positive changes in our 
physiology and interpersonal relation- 
ships. Siegel says attunement can lead to 
improved immune function, a sense of 
well-being, an increased connection to 
loved ones, and neural integration, 
which contributes to mental flexibihty 
and self-understanding. 

The Beautiful Skin Workout 

Eight Weeks to the Smoothest, Healthiest Skin 
of Your Life, by Michelle Copeland '77 
with Megan Deem (Griffin, 2007) 



The skin reveals all our secrets, says 
Copeland, particularly our sun-worship- 
ping, latte-slurping vices. But she has a 
cure to return all that alhgator skin to 
its former creamy self. Her eight-week 
regimen includes cleansing, exfoliating, 
slathering on the right lotions, eating 
foods rich in omega-3s and antioxidants, 
and exercising. 

Treatment Kind and Fair 

Letters to a YoungDoctor, by Perri Klass '86 
(Perseus Books, 2007) 



The young doctor to whom the ten letters 
in this book are written is the author's 
son, Orlando. He has decided to foUow in 
his mother's footsteps, and Klass has wis- 
dom to impart. She considers the chal- 
lenges of entering medicine — such as pal- 
pating a patient's "squishier parts" for the 
first time — and the changes resulting 
from technology and legislation, such as 
the blessings and hardships of a mandated 
80-hour workweek during residency. 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



\« 



REVIEWING THE PRINTED WORD 



ROOKMAHK 



To Die Well 



Your Right to Comfort, Calm, and Choice in the Last Days of Life, 
by Sidney Wanzer, MD and Joseph GlenmuUen '84 
(Da Capo Press, 2007) 

YOUR GOOD DEATH — IN WHICH ALL FLOWS TOWARD A GENTLE 

end — ^will require clarity of thought and strategies laid out long 
before circumstances necessitate them. Resist the hope that 
this will happen without active intervention, warns Sidney 
Wanzer, writing in collaboration with Joseph GlenmuUen '84. 
No one will ever care as much about how you die as you wUl. 
Maintain vigilant control. You are at stake. 

To Die Well takes only a few hours to read — ^but life- changing 
hterature does not need to be encyclopedic. "I think every 
dying patient and his or her family should 
consider drawing up detailed instruc- 
tions for the final days," Wanzer writes. 
Then he helps us to do so. 

Clearly defined goals are the most 
important part of instruction. The first 
comes when a patient opts for comfort 
care instead of aggressive treatment. All 
the symptoms of dying — lethargy, 
weakness, anorexia — must suddenly be 
separated from symptoms of distress, 
such as anxiety, dyspnea, and pain. The 
former are to be respected, the latter 
managed. It means prescribing addictive 
medications without fear of causing 
addiction; "the proper dose of any anal- 
gesic... is the amount necessary to 
relieve pain." It also means that treat- 
ments can be refused or even discontin- 
ued. This is a concept that undermines 
our Newtonian expectation that bodies 
in motion will remain so. Comfort care 
means changing speed and course. 

Through changes of speed and course, interventions that 
formerly were accepted now prolong the dying process. That 
seems simple enough; palhative care is no longer seen as an 
eccentric field. Yet, as Wanzer writes, "it is amazing how many 
people feel it is somehow improper to stop a treatment that 
has already been started." "Treatment" may include food and 
water. In one of many startling educational moments, the 
author disposes of the idea that withholding fluids is cruel, 
pointing out that dying patients do not feel extreme thirst and 
distress because "the dying process impose[s] a form of auto- 
sedation in which all senses are dulled, including the sensation 
of thirst." He adds, with a logic one cannot deny, that giving 
fluids to a patient who does not want them anymore "could 
[even] be considered battery." 




So ends the less controversial part of the book. Next Wanzer 
looks the devil in the eye; When should the clearly defined goal 
be to hasten death? By the time this question arises, "even 
meticulously rendered maximum comfort care is not enough 
to control a dying person's intolerable suffering." Pain control, 
consultations, and efforts to diagnose depression or other 
reversible conditions have all occurred, yet stiU "the situation 
declares itself [as] undeniable." Deliberately hastening death 
under these circumstances may seem so sensible that it's 
almost difficult to understand what all the fuss is about. 

The fuss, for those who will make it, comes after reading the 
chapters that follow. Wanzer is very practical. He warns that 
guns and carbon monoxide are to be avoided; taking nine to 
ten grams of barbiturates is a much more reliable strategy, as is 
using one to two tanks of 100-percent hehum. 

In simple words, Wanzer answers the 
questions we might fear to ask in the hti- 
gious hght of day ("if a barbiturate is 
stored in a dry environment at room tem- 
perature (not in the refrigerator) it prob- 
ably retains potency for a few years 
(maybe five or seven)." What a rehef to 
know this. It is as if he were sitting in a 
sunht kitchen with us, sharing tea and 
tips for keeping yeast fresh. There is noth- 
ing iUicit in the conversation he holds, no 
hysterics or drama. His voice is fuU of 
good manners and deep experience; he 
accepts another cup of tea — thank you, 
no more cake — and continues. 

Here is a book so dense with diEerent 
kinds of wisdom that one chapter reph- 
cates the technical documents you need 
to make your wishes clear, while another 
discusses behavior in the presence of the 
dying. "Sit close with your head on a level 
with the patient's," this wonderful doc- 
tor recommends, "speak of the good 
things he or she has meant to you, and you will do fine and will 
be a comfort." 

We are interested mostly in our own good deaths, of course, 
and Wanzer ends with a hst of "Essentials for Staying in Con- 
trol." From a medical man, some of the advice is chilhng; for 
instance, "avoid transfer to the hospital unless it is clearly nec- 
essary for the control of symptoms." Even doctors don't want 
to die badly, and the very specialists who run the system also 
fear being at its mercy. Until physician- assisted death is legal- 
ized across the country, brave doctors (Wanzer is a leader 
among them) will be left searching for ways to protect their 
patients from their profession. ■ 

Elissa Ely '88 is a psychiatrist at the Massachusetts Mental Health Center 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



15 



BENCHMARKS 



DISCOVERY AT HMS 



Served with a Twist 




T FIRST THE SCENE IS A FAMILIAR 

one: A man stands in front of 
a mirror, lathers cream on his 
face, and proceeds to shave — 
but with a roUing pin. What happens in 
our brains when what we hear or see 
doesn't jibe with what we expect? 

Over the past eight years, researchers 
at Massachusetts General Hospital have 
been attempting to answer this question 
by analyzing study participants' reac- 
tions to all manner of verbal and visual 
surprise endings — sentences with unex- 
pected or outlandish 
words and video clips 
with anomalous or down- 
right bizarre final images. 
Using a combination of 
methods that detect when 
and where neural activity 
occurs, they have been 
comparing how our brains 
react to the merely unex- 
pected scenarios versus 
the wildly strange ones. 

Their findings show 
that both types of anom- 
alies are processed in less 
than a second, but more 
outlandish ones take a bit 
longer. The delay, a mere 
200 milliseconds, is accompanied by 
brain activity similar to that which 
occurs when we grapple with grammat- 
ical mistakes, instead of the errors of 
meaning that these anomalies represent. 

Now Gtna Kuperberg, a lecturer on 
psychiatry at Massachusetts General 
Hospital, and colleagues have used these 
differences in timing and activity to 
develop a new model for how we make 
sense of such events. In the May 18 issue 
of Brain Research, Kuperberg reports that 
comprehension occurs along two inter- 
acting neural streams. The first, and 
faster, occurs as the brain attempts to 
map new input to what it already has 
seen or experienced. When this initial, 
more rigid memory-based system fails — 



because the new input appears too unfa- 
mihar or nonsensical — another wave of 
brain activity starts up. This may hint at 
a second system that compares the rela- 
tionship between subject and action to 
an implicit set of rules to determine 
whether the action is feasible. 

Prepared for the Impossible 

The research indicates that both memo- 
ry-based and action-based streams are 
called into play regardless of the length 




of the event, for short sentences or video 
chps as well as for long sequences con- 
veyed in stories and movies. And streams 
may be provoked by ordinary events, not 
just the unexpected or outrageous. 

The first system makes use of prior 
real-world knowledge stored in memory 
to guide everyday comprehension and 
prepare us for likely future scenarios. But 
the matching goes only so far, and then 
the brain must engage, and cultivate, a 
more flexible route that might better 
prepare us for extraordinary events. 

A key feature of the model is that the 
two systems exist in balance, a charac- 
teristic that enables us to deal with a 
world that is both famihar and novel. 
For people with schizophrenia or other 



psychiatric disorders, however, this bal- 
ance may be thrown off. 

Bread, Butter, and Socks 

Kuperberg's captivation with the 
bizarre patterns of thought and speech 
of her schizophrenic patients took root 
during her psychiatry training, when 
linguistics and cognitive science were 
governed by the classic distinction 
between syntax and semantics. That 
distinction has been reified by two 
recent discoveries. 

In 1980, researchers 
at the University of 
California in San Diego 
found that study partic- 
ipants exhibited an 
event-related potential, 
a standard measure of 
brain activity, 400 mil- 
liseconds after hearing a 
semantic violation such 
as "She spread the bread 
with butter and socks." 
The change, called the 
negative-going 400, or 
N400, reflected the 
direction of the record- 
ed brain activity and 
was considered a sign of semantic pro- 
cessing. In 1992, Tufts University scien- 
tists observed an opposite change in 
brain activity 600 milliseconds after 
subjects heard or read a sentence that 
violated syntax. This change, called the 
positive-going 600, or P600, was consid- 
ered a mark of syntactic processing. 

Kuperberg set out to explore the 
semantic side of the equation. She pre- 
sented healthy participants with two 
confusing sentences — "Every morning 
for breakfast the boys would plant" and 
"Every morning for breakfast the eggs 
would eat" — and monitored their brain 
activity. The first, an unlikely but possi- 
ble proposition, evoked the N400 in 
subjects. The second, a patently impos- 



16 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



Trash Talk 



sible statement, produced a robust 
P600. Meanwhile, her colleagues 
had been producing video clips 
containing strange final images, 
such as a birthday cake being cut by 
a baseball bat or a man shaving 
with a rolling pin. Upon watching 
these clips, participants exhibited 
the P600. 

A series of functional MRI studies 
helped Kuperberg and colleagues 
decipher the various findings. The 
studies found that participants 
who were presented unlikely sce- 
narios in sentences and in video 
clips processed the information in a 
rather restricted set of brain struc- 
tures. When presented with out- 
landish or impossible scenarios, 
however, the participants' brains 
called on a wider network — one 
that resembled the distribution of 
newly discovered neurons. 

The researchers speculate that 
two different mental mechanisms 
are at work within the semantic sys- 
tem — a first-pass or memory-based 
system and a flexible, action-based 
system that ramps up under specific 
circumstances. But questions remain. 
The action-based system appears to 
be triggered by violations to the rela- 
tionship between an action and its 
allowable subjects, all moderated by 
the context within which the rela- 
tionship is presented. In processing 
a children's story, for example, our 
brains might not think twice about 
eggs eating. 

"We don't really know what 
triggers the reprocessing or what 
the nature of this reprocessing is, 
only that it happens in certain situ- 
ations," says Kuperberg. "Now 
we're figuring out what those situ- 
ations are." ■ 

Misia Landau is a senior science writer 
for Focus. 




TICKS AND STONES MAY 

break my bones, but 
words will never hurt me." 
Not so, says a report 
in the April issue of the Harvard Men- 
tal Health Letter. Research by McLean 
Hospital psychiatrists indicates that the 
constant, severe verbal abuse of chil- 
dren creates a risk of post-traumatic 
stress disorder, the type of psychologi- 
cal collapse that affects some combat 
troops in Iraq. 

In published and soon-to-be-pub- 
lished findings, the researchers found 
that scolding, swearing, threatening, 
blaming, demeaning, yelling, ridicul- 
ing, insulting, and criticizing can be 
as harmful as physical abuse, sexual 
abuse outside the home, or witness- 
ing physical abuse at home. Chil- 
dren who are mistreated this way 
exhibit higher rates of physical 
aggression, delinquency, and social 
problems than other children. 

"Exposure to verbal aggression has 
received little attention as a specific 
form of abuse," says Martin Teicher, 
an HMS associate professor of psychi- 
atry who led the McLean Hospital 
research team, "despite the findings 
that 63 percent of American parents 
reported one or more instances of 
verbal aggression, such as swearing 
at or insulting their child." 



Other researchers have found that 
children who experience verbal abuse 
have a significantly higher risk for 
developing unstable, angry personali- 
ties; narcissistic behavior; obsessive- 
compulsive disorders; and paranoia. 

The McLean team studied the 
impact of childhood verbal abuse in 
both the presence and absence of 
physical and sexual abuse and expo- 
sure to family violence. Their initial 
study — involving 554 participants 
between the ages of 1 8 and 22 — 
showed that verbal abuse had as 
great an effect as physical or nondo- 
mestic sexual mistreatment. Verbal 
aggression alone was a particularly 
strong risk factor for depression, hostil- 
ity, and dissociation disorders, condi- 
tions that con cripple a person's ability 
to form interpersonal relationships or 
build self-esteem and coping strategies. 

Recent research by the team shows 
that exposure to verbal abuse also 
affects brain areas linked with 
changes in verbal IQ and symptoms of 
depression, dissociation, and anxiety. 

The take-home message is that the 
occasional harsh word will not trau- 
matize a child for life. Frequent ver- 
bal bashings, however, will. ■ 

William J. Cromie is a staff writer for 
the Harvard University Gazette. 




SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 17 



RKNCHMARKS 



DISCOVERY AT HMS 




Roof of the Matter 



EARLY 4,000 YEARS AGO, HEALERS 

in Pharaonic Egypt compiled 
a medical treatise with some 
of the earliest descriptions of 
what we today know as schizophrenia. 
Writing in the "Book of Hearts," a chap- 
ter of the Ebers Papyrus, one of the old- 
est extant medical documents, ancient 
physicians detailed what they consid- 
ered to be a physical illness that involved 
the heart, a condition spawned when 
purulence, poison, or demons fouled the 
blood vessels. Pharaonic psychotherapy 
recommended temple sleep. Treatment 
centers proliferated and included one 
on the island of Ptulae that was built in 
honor of lemhotep, one of the earhest 
physicians in recorded history. 

Today, temples do not often double as 
clinics, and sleep is an unlikely pre- 
scription for any of the more than 1 per- 
cent of the world's population who suf- 
fer from this devastating disease. Yet 
although schizophrenia is now firmly 
associated with the brain, and its mani- 
festation eased by pharmaceutics, its 
cause — and cure — remain as mysteries. 

A recent attempt at their solution, 
however, may provide some of the best 
evidence to date that the root of this dis- 
order hes within the brain's white matter 
and the genes that control its develop- 
ment. Researchers at Children's Hospital 
Boston have shown that changes in sig- 
nals passed between a growth factor 
involved in brain development and the 
receptor it docks to on the surface of 
brain cells can both alter white matter 
function and structure and lead to 
behaviors suggestive of mental illness. 

These discoveries were made by a 
research team from the Neurobiology 
Program at Children's Hospital. The 
investigators, led by Gabriel Corfas, an 
HMS associate professor of neurology, 
reported their findings in the May 8 
issue of the Proceedings of the 'National 
Academy of Sciences. 

Although previous investigations by 
other scientists had linked schizophre- 




nia to genes for the growth factor 
neuregulin 1 (NRGl) and the brain- cell 
receptor erbB4, none had shown 
whether alterations in these genes could 
actually produce psychiatric disorders. 
Corfas and his team chose to probe that 
possible link. 

Acting on Impulse 

The brain is a dense network of nerve 
cells that function like their cousins 
throughout the body — that is, they 
transport pulsed packets of informa- 
tion. Each nerve cell, or neuron, serves 
as both a transmitter and receiver of 
these impulses. In the simplest such 
arrangements, impulses are received by 
branched structures, known as den- 
drites, which extend from a neuron's 
cell body. Received impulses move 
through the cell body and on to the 
axon, a long fiber that ends in branched 
terminals that chemically communicate 
the impulse to dendrites of other neu- 
rons. These interconnections among 



thousands of neurons allow information 
to travel from throughout our body to 
our brains. 

The brain processes the reams of 
information delivered to it in its own 
networks of neurons. These networks 
are dense, highly intercoimected, and 
lightning quick, this last characteristic 
aided by the biological insulation called 
myehn, a light- colored, fatty sheath that 
insulates each neuron's axon so effi- 
ciently that impulses can hterally jump 
along an axon's length. The whitish 
appearance of these densely packed 
neuron networks has led to their being 
referred to collectively as the brain's 
white matter. 

Altered States 



Working with mice as a model system, 
the team set about blocking signals 
exchanged by NRGl and erbB4 in ohgo- 
dendrocytes, ceUs whose branches make 
up the myehn that wraps the axons of 
brain neurons. Although the mice with 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



blocked signals actually produced more 
oligodendrocytes, the researchers discov- 
ered the oligodendrocytes had fewer 
branches and produced thinner myehn 
sheaths. With less insulation protecting 
the axons, the nerve fibers conducted 
impulses more slowly. 

The mice also showed a heightened 
sensitivity to amphetamine, a sign that 
there had been changes in the nerve 
cells that produce and use dopamine, a 
chemical that helps ferry impulses from 
axon terminals to dendrites. 

"Changing the white matter in the 
brain apparently unbalanced the 
dopamine system," says Corfas, "some- 
thing that also occurs in patients with 
neuropsychiatric disorders." 

Most interesting, perhaps, were the 
behavioral changes exhibited by the 
mice whose NRGl-erbB4 signaling 
pathways had been blocked. In these 
mice, the researchers noted a reduction 
in social interaction reminiscent of the 
decreased initiative and social with- 
drawal found in people suffering from 
schizophrenia. In addition, when placed 
in a box, the mice hugged the walls and 
engaged in other behaviors suggestive of 
anxiety, yet another symptom associat- 
ed with schizophrenia. 

If schizophrenia does develop from 
defects in the brain's white matter, as 
the study suggests, the findings may 
help explain why the disorder often is 
diagnosed during late adolescence and 
early adulthood. Recent research indi- 
cates that myelination of the prefrontal 
cortex, the brain region implicated in 
schizophrenia, occurs not only in infan- 
cy and toddlerhood, but also during 
adolescence and early adulthood. 

"We need to go back to patients with 
schizophrenia and see whether those 
with variants of the NRGI and erbB4 
genes have differences in their white 
matter," say Corfas. "It may be that 
changes in different genes produce dif- 
ferent kinds of schizophrenia and that 
directed treatments are possible." ■ 



Research Digest 




lllll^ GENERATIONAL CHANGE 

It may be time to scale back weight- 
gain recommendations for pregnant 
women, say researchers at the Depart- 
ment of Ambulatory Care and Preven- 
tion, a joint clinical effort of HMS and 
Harvard Pilgrim Health Care. In the 
April issue of the American Journal of Obstetrics and Gynecology, the scien- 
tists report that women who gain excessive — or even appropriate — weight 
according to current standards are four times more likely to have babies 
who will be overweight by age three than women who gain less than the 
allowed levels. Current guidelines, issued by the Institute of Medicine in 
1 990, may not be valid for U.S. women today, says lead author Emily Oken, 
an HMS instructor in the Department of Ambulatory Care and Prevention. 

illli^ BINDING RESOLUTION 

Halting tumor growth for non-small-cell lung cancer has proven perplexing to 
medical science. Tumors that at first respond to targeted pharmaceuticals such 
as gefitinib and eriotinib later become resistant and resume their growth. 
Hints of why this happens were uncovered three years ago, when researchers 
at Massachusetts General Hospital and Dana-Farber Cancer Institute found 
that approximately half of the tumors that initially respond to treatment 
become resistant after a secondary mutation kicks in and alters a cancer-cell 
surface protein, thus preventing the tumor-stemming drug from binding. The 
researchers recently focused on the growth-triggering mechanism in resistant 
tumors that do not have this secondary mutation. Reporting in the May 1 8 
issue of Science, the team identified the culprit: a facilitator protein produced 
by an oncogene not targeted by the drug therapies. They speculate that such 
tumors may respond to combination therapy aimed at both protein targets. 
They also suggest that repeat biopsies may help identify the resistance mecha- 
nism at work, information that would help physicians better determine thera- 
py. The team was led by Jeffrey Engelman, scientific director of the Center for 
Thoracic Cancers at Massachusetts General Hospital. 

Illli^ UPPING DANTE 

Sun, seafood, and specific supplements should be on men's must-have lists, 
especially during seasons when days are short, say scientists at Brigham and 
Women's Hospital and the Harvard School of Public Health. Why? All three 
increase vitamin D levels — and help protect men against prostate cancer. In 
an 1 8-year study of nearly 15,000 physicians, 496 of whom died from 
prostate cancer, the researchers found that two-thirds had seasonal insufficien- 
cies of vitamin D. By measuring two blood protein markers and forms of a 
gene involved in vitamin D absorption, the scientists found men with the low- 
est marker levels and particular genetic profiles were at greatest risk for an 
aggressive, often deadly, form of prostate cancer. The study was reported 
March 19 in PLoS Medicine by team leader Haojie Li, an HMS instructor in 
medicine at Brigham and Women's Hospital. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



TRIBUTE TO JOSEPH MARTIN 



Strong 

Medicifre 



fter a decade of rich service, Joseph Martin leaves a legacy that 
nil loner mark mpdicine at Harvard, hy George E. Thibault 




Early in his tenure as dean of Harvard Medical School, 
Joseph Martin made a gesture that would come to symbolize his 
decade in the position: He literally opened the doors to the insti- 
tution. Upon greeting the first incoming class of his deanship, he 
announced that the front doors of Gordon Hall — then Building A — 
would remain unlocked every weekday instead of just once a year, 
at graduation. This gesture, he said, was meant to signify the School's 
openness and accessibility to all communities, whether the sur- 
rounding neighborhood, the community of greater Boston, the 
country, or even the world. 



20 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



mttmm 



BRIDGE BUILDER: Under Joseph 
Martin's leadership, community 
outreach and public service both 
became fundamental to the mis- 
sion of Harvard Medical School. 




"Some people believe that public service is merely an 
option for a private institution like Harvard Medical 
School," he said. "I do not. During my tenure here, com- 
munity outreach and service will remain an individual 
choice, but will be a mandate for HMS as an institution." 

Joe stepped down as dean in June 2007. During his 
tenure he exemplified the principles of public service and 
community building at Harvard Medical School. The hst 
of his accomphshments is long, but I find they cluster 
around the themes of building collaboration, promoting 
diversity, strengthening science, and reforming education. 



When Joe arrived from the University of California at 
San Francisco in 1997, he was no stranger to HMS, having 
previously served as chief of neurology at Massachusetts 
General Hospital. But he came at a time of transition in 
the marketplace. The economic pressures of managed 
care, the formation of Partners HealthCare by Massachu- 
setts General Hospital and Brigham and Women's Hospi- 
tal, and the merger of the Beth Israel and Deaconess hos- 
pitals had all created tensions and competition that 
threatened faculty collaboration and interdisciplinary 
academic endeavors. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



21 



Without his steadfast support, the ideas 
tliat led to a maiorxurricuJum reiorm 
would not have been nurtured. 



With his calm demeanor and highly principled 
approach to all conflicts, Joe set out to calm the trou- 
bled waters and to improve relationships among the 
affiliated hospitals and between the hospitals and the 
Medical School. He did this by visiting each of the hos- 
pitals regularly and by convening leadership meetings 
to find areas of common ground. He took the bold step 
of successfully petitioning the University to increase 
the payout on the 102 endowed professorships based at 
the hospitals, and he asked the clinical departments to 
use these new resources — more than $20 million over 
five years — to support teaching. 

Joe promoted efforts for cross-institutional collabora- 
tive research, which resulted in significant new funding 
and major new initiatives. Among the more notable of 
these successes were the Juvenile Diabetes Foundation 
Center for Islet Cell Transplantation, the Dana- 
Farber/Harvard Cancer Center, the Harvard Chnical 
Research Institute, the Harvard Medical School/Part- 
ners Center for Genetics and Genomics, and the Harvard 
Center for Neurodegeneration and Repair. To give but 
one example of the power of the collaborations he pro- 



moted, the Dana-Farber/Harvard Cancer Center collab- 
oration resulted in a $50 miUion grant, the largest ever 
given by the National Cancer Institute. 

In the area of diversity, Joe called for a review that 
led to the promotion of more women and minorities, 
and he worked with hospital leaders and search com- 
mittees to adopt a more aggressive approach to 
recruiting minorities for faculty positions. His own 
leadership team reflected his commitment to diversity 
He named women as chairs of two of the Quad's 
departments: Carla Shatz in neurobiology and Joan 
Brugge in cell biology. He appointed Nancy Andrews '87 
the first dean for basic sciences and graduate studies, 
and he named Cynthia Walker the first female execu- 
tive dean for administration. In naming Joan Reede as 
dean for diversity and community partnership, he was 
appointing the first female African American dean in 
Harvard's history. 

Joe's record in strengthening science at HMS is 
revealed partly in the collaboration story and partly in 
the quality of his chair appointments. But there is 
more to be told. He opened the 525,000-square-foot 



A Decade of Leadership 




1QQ7 

A-^ _7 ( Martin announced the 
opening of the front doors of Building A 
to symbolize the School's accessibility to 
all communities, whether local, national, 
or international. 



IQQS 

_L_7 ^ \J Neil Rudenstine, then president of 
Harvard University, and Donnella Green '99, then 
an MD-PhD candidate in neurobiology, joined 
Martin in celebrating the 30th anniversary of 
affirmative action at the School. 



1998 



In welcoming the Class of 2002, 
Martin encouraged the students to think about how 
they could best serve their fellow students, profes- 
sors, and patients — even as they became immersed 
in their studies. 



22 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



New Research Building, the largest building in the his- 
tory of the University. This site was created to promote 
close collaboration between Quad- and hospital-based 
scientists. In starting the Department of Systems Biol- 
ogy he created the first entirely new basic sciences 
department at HMS in more than 20 years. He pro- 
moted other new interdisciplinary initiatives, such as 
the Center for Molecular and Cellular Dynamics, the 
Harvard Institute for Proteomics, the Center for 
Genomic Applications and Therapeutics, and the Pro- 
gram in Chemical Genetics. 

In the second half of his tenure as dean, Joe turned 
his attention to the issue of medical education, and it is 
quite appropriate that this tribute to him is included 
alongside the special report on medical education. He 
had the prescience to found the Academy at HMS as a 
statement about the importance of teaching and as a 
catalyst for educational reform. Without his steadfast 
support, this would not have happened, and the ideas 
that led to a major curriculum reform would not have 
been nurtured. He also had the insight that education- 
al reform would not be enduring if we did not address 





2001 



.Joining Martin in the groundbreaking 
for the New Research Building were, from left, Mark 
Moloney, then director of the Boston Redevelopment 
Authority; then Harvard president Neil Rudenstine; 
and Boston Mayor Thomas Menino. 



9009 

^—\J\J.^ In his State of the School address, Martin 
emphasized the HMS mission statement: to create and 
nurture a community of the best people committed to 
leadership in alleviating human suffering caused by disease. 
He later odded the word "diverse" before "community." 



2003 



Then Harvard President 
Lawrence Summers and Martin cut the 
ribbon on the New Research Building, 
dedicating it to collaborative science. The 
building is the largest in Harvard's history. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



23 



Joe's success was based on a style of 
leadership that brought out the best i 
the people and institutions around him. 



the important faculty issues of promotion, compensa- 
tion, and teaching competence. 

Among his most important legacies will be a new set 
of promotion criteria, a new cooperative plan between 
the School and the affiliated hospitals for compensat- 
ing teachers, and the new Academy Center for Teaching 
and Learning — all directed at enhancing the careers of 
the faculty who teach. In addition to these contribu- 
tions to the quality of education at HMS, Joe worked 
closely with the Alumni Council and the Board of 
Fellows on initiatives to tackle the staggering problem 
of student debt. 

This list of accomplishments is impressive. But Joe's 
real impact as dean was more remarkable than any such 
list. His success was based on a style of leadership that 
brought out the best in the people and institutions 
around him. Nancy Oriol 79, now the dean for stu- 
dents, recently captured that style when she described 
a moment at the beginning of her new role as associate 
dean for student affairs, which coincided with the start 



of Joe's tenure as dean of the School. At the opening of 
orientation, Nancy stepped back to let Joe enter the 
room of new students first. But he motioned her to go 
ahead of him, saying, "You can lead us in." 

"Since that day," Nancy told me, "he continued to 
help me 'take the lead' and encouraged me to usher in 
many new programs and ideas — always behind me as 
an advisor and supporter." 

Joe's habits of encouraging others, stepping out of 
the spotlight, and leading by listening, as he described 
in his recent Class Day address, are all characteristic of 
his leadership style. He has used his moral authority 
without appearing to be using it, and in doing so he has 
left HMS a better place. We are all indebted to Joe for 
opening the doors. ■ 

George E. Jhihault '69 is vice president of clinical ajfairs at Partners 
Healthcare System, Inc. At Harvard Medical School he is the 
Daniel D. Federman Professor of Medicine and Medical Education, 
the director of alumni relations, and the director of the Academy. 



I 




9004 

.^- vy V_/ T Charles Hatem '66 (center) and George 
Thibault '69 joined Martin in unveiling a portrait of the 
late Harold Amos, the first African American to chair an 
HMS department, at the establishment of the first Academy 
professorship, named in Amos's honor and held by Hatem. 



.^ V/ Vy Vy Martin led a celebration of the 
centennial of the School's original Quadrangle. 
Three scientific symposia touched on 1 00 years 
of biomedical progress and looked ahead to the 
next century of scientific discovery. 



9007 

^l-KJKJ ( Jack Connors, Jr., chair of the 
HMS Board of Fellows, presented Martin and his 
wife, Rachel, with an architectural rendering of 
the newly named Joseph B. Martin Conference 
Center at Harvard Medical School. 



24 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



TRIBUTE TO JOSEPH MARTIN 



Leading by 

Listerdn 




Intelligence and empathy are just two of the qualities that can 
turn good physicians into gifted leaders, hy Joseph B. Martin 



In The Story of a Shipwrecked Sailor, Nobel 

Prize-winning author Gabriel Garcia Marquez recounted a true 
tale of eight Colombian sailors. While returning home in their 
destroyer, they encountered a storm so severe that seven of the 
men wtrt cast overboard. The lone survivor drifted in a small, 
half- inflated raft v/ithout food or w^ater. Finally, after ten days, he 
w^ashed ashore. There, lying on the sand, half- conscious, he w^as 
approached by a man who asked v/hat had happened. 

"When I heard him speak," the sailor later said, "I realized that 
more than thirst, more than hunger, more than despair, what 
tormented me most was the need to tell someone what had hap- 
pened to me." 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 25 




Everyone has a story to tell. All patients have a story — 
thdr story — that is inextricably linked to the healing 
process. As doctors we are expected to be good hsteners. 
We are expected to hsten to the stories our patients tell us 
and to reach conclusions that will lead to the best recom- 
mendations for their care. The ability to communicate well 
determines in large measure a doctor's gift for healing. 

These same skills of listening and telling are just as 
critical when doctors achieve positions of leadership. 
And so I want to reflect on what I describe as six char- 
acteristics of gifted leadership. I call them quotients, or 
Qs, of leadership. 

This first is IQ — our old friend, the intelligence quo- 
tient. Howard Gardner, a professor at the Harvard 
Graduate School of Education, has described what he 
calls multiple intelligences. In fact, efforts to define 
intelligence fill the pages of psychology and neurobiol- 
ogy journals and books. I take intelligence to encom- 
pass the ability to imagine, learn, remember, synthesize, 
create, analyze, differentiate, construct new paradigms, 
and problem solve. 

IQ imphes the abihty to innovate. Obviously, aspking 
leaders ought to have a distinguishing level of inteUi- 
gence. But inteUigence alone is not enough. Individual 



brilhance may result in earthshaldng concepts, discover- 
ies, and Nobel prizes, but of leaders we expect even more. 

The second mark of leadership is EQ, the Emotional 
Quotient. This is the abihty to empathize, to under- 
stand the impact of group dynamics on the outcome of 
a situation, to be able to reflect on one's own reactions, 
to commiserate, and to share another's disappointment 
and pain. Simplified, it is the abihty to listen and to dis- 
cern what the other person is really saying. 

Daniel Goleman, the author of Emotional Intelligence, 
defines the competencies of emotional inteUigence as 
self-awareness, self-management, empathy, and rela- 
tionship skills. EQ requires enough temerity and 
curiosity to want to understand another's perspective. 
EQ is learning to lead by hstening and observing. 

The third characteristic is HQ, the Humor Quotient. 
This quotient encompasses the capacity to recognize 
the ridiculousness and humor of a situation, to use self- 
deprecation to accomplish an end, and to exude a sense 
of lightness of being and charisma, of good cheer and 
hope. HQ is the abihty to detoxify a situation by humor 
or self-effacement, to know how to relax the tension 
with a comment, a story, or a well-told joke. It is the 
ability to bounce back after an untoward event. 



26 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



As doctors we are expected to be good listeners. 
The abijitv to communicate well 



in large measure a doctor's 



Leiprmmes 
:t tor nealins 



The historian Doris Kearns Goodwin hnks humor to 
psychiatric approaches. "Modern psychiatry," she says, 
"regards humor as probably the most mature and 
healthy means of adapting to melancholy." 

George Vaillant '59, a well-known Harvard professor 
of psychiatry, recently wrote, "Humor, like hope, permits 
one to focus upon and to bear what is too terrible to be 
borne." VafUant also offered a sahent quote from a friend: 
"Humor can be marvelously therapeutic. It can deflate 
without destroying; it can instruct while it entertains; it 
saves us from our pretensions; and it provides an outlet for 
feehng that expressed another way would be corrosive." 

The fourth quotient is CQ, the Contentment Quo- 
tient. This is the abihty to view situations with an eye to 
the best possible outcome — a glass half full, not half 
empty. CQ allows one to feel good about oneself and the 
role one plays. It balances good will and good cheer with 
an appropriate level of anxiety to set things on course 
and to reach the desired outcome. This quotient requires 
sufficient self-knowledge to feel confident about one's 
course of action and to end the day with a sense of a job 
well done, with an abihty to sleep well and awake feeling 
rested and ready to take on the challenges of the next day. 

This quotient includes the ability to view life as a 
great adventure, approached with the right modicum of 
self-assurance to know what decisions need to be made. 
It also demands sufficient confidence in the tightness of 
a position or decision to avoid the snake pit of many 
failures — procrastination. 

CQ thrives in successful social arrangements and is 
confident that sharing can provide the deepest meaning 
in interpersonal relationships. It avoids the dangers of 
promiscuity, of drug and alcohol abuse. It imphes enough 
security in one's own sense of self-worth to avoid feehng 
threatened by adversaries, disagreements, or challenges. 

Number 5 is GQ, the Generosity Quotient. In many 
ways a singularity of leadership success is epitomized 
in the term "vicarious living." It is the joy and satisfac- 
tion that accompanies watching the success of others. 
In an organizational setting, it involves freely giving 
credit where credit is due, recognizing that, as Harry S. 
Truman once said, "It is amazing what you can accom- 
plish if you do not care who gets the credit." 

There is another aspect to GQ: the ability to forgive 
and forget. Holding a grudge is a powerful disincentive 
to progress. It is impossible to hold a position of leader- 
ship without being the recipient of bad news — news 
that may reflect on your own performance or on per- 
ceptions of you as a leader. The source of such deroga- 
tory comments may come from important individuals 



whose roles in subsequent actions are critical. It is 
important to make an effort to understand the context 
of the criticism. Harboring negative feelings that arise 
from the inability to appreciate the potential value of 
the comments v^oll lead to the development and perpet- 
uation of counterproductive relationships. 

The sixth mark of leadership is WQ, the Wisdom 
Quotient. Wisdom entails the abihty to know when 
enough information is in hand to make a decision. Simply 
put, it is knowing when to pounce. The 80/20 rule holds 
that you should act with 80 percent of the information in 
hand, without worrying about the other 20 percent. 

WQ includes the ability to understand and to know 
when to apply Machiavellian principles to reach a good 
end. But it also requires the principles of fairness, of 
reaching the decision that is the best for the most, char- 
acterized by equity and equality when possible. 

Wisdom is sound judgment, which stems from the 
critical characteristics of integrity and honesty. WQ rec- 
ognizes that success depends on a consistent set of behav- 
iors that most people would identify as trustworthiness 
and rehabihty. WQ also acknowledges the importance of 
treating people fairly and consistently. 

Leadership without motivation will likely fail. Any- 
one aspiring to success will enjoy the recognition that 
comes from wealth, power, prestige, and honor. Fear of 
failure is a powerful, almost universal motivating force. 
When applied appropriately, it can direct and guide 
ambition. Ambition with good judgment implies the 
ability to organize and analyze the data available and to 
take action, usually without remorse. 

Second-guessing a decision can be a powerful inner- 
vating adventure. If a decision proves to have been 
wrong, it can be corrected. WQ recognizes the impor- 
tance of apologizing when things go awry; apologies 
should be sincere and brief. 

We are all sailors on the voyage of life. Each of the 
areas I have emphasized — intelligence, emotional con- 
nectivity, good humor, happiness, generosity, and sound 
judgment — can be enhanced by good listening. I'm not 
implying that these traits or attributes are necessarily 
quantifiable as quotients. But I do offer them as a set of 
guideposts as you continue the great journey of life. ■ 

Joseph B. Martin, MD, PhD, gave these remarks during his final 
graduation ceremony as dean of Harvard Medical School. Since 
stepping down after ten years in the position, Martin became the 
Edward R. and Anne G. Lefler Professor of Neurobiology at EMS. 
He plans to devote his time to the Harvard Center for hleurodegen- 
eration and Repair 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



27 



SPECIAL REPORT 



DESIGN FOR HEALING 



After rolling out its first major curriculum reform 

in a generation, Harvard Medical Schoo.. 
receives a report card, hy Rich Barlow 



T WAS THE FINAL EXERCISE OF THE COURSE THAT MADE ARETHA 

Delight Davis 10 think of her father's terminal cancer. That exercise 
ended a two-week introduction to Harvard Medical School's first cur- 
riculum reform in a generation. Traditionally, cadavers serve as incom- 
ing Students' initiation into medicine. Last August, though, Davis's | 
class had been greeted by Introduction to the Profession, a short j 
course that sent the students on rounds and gave them glimpses iato | 
the hves of working physicians, from interviewing patients to role- I 
playing as part of a medical team responding to emergencies. To cap | 
this early immersion into medicine, the professor asked the students to J 
write a letter to themselves as iust- graduated doctors, four years hence. I 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



he traditional clerkships didrit allow students 
1 onnorn inifv to h! i \ ^ ^ '', ^^^ 

care relationships with patients. 



Davis had chafed at the course's summer start; she'd 
worked in her former job right up to the beginning of 
school. Her skepticism spiked when the precourse 
readings included such selections as The Spirit Catches 
You and You Fall Down, a recounting of a Hmong family's 
culture clash with U.S. medicine. "I'd dealt with similar 
conflicts in my former life as a lawyer," she says, "and I 
felt like I'd been there and done that." Yet the glimpses 
of healing she'd seen during the course had revealed 
medicine's compassionate core — and banished her 
skepticism of the course's value. 

Now, addressing her future self, she wondered 
whether her father could beat his cancer long enough to 
see her graduate. Would the time-devouring demands 
of her studies trump keeping in touch with him and 
others who mattered to her? If that happens, she wrote 
in her letter, be sure to reconnect, so a sense of empti- 
ness doesn't degrade your work as a doctor. 

Then, oblivious to the 200 students surrounding her 
in the lecture hall, she wept. 

Davis's emotional burden may well have mirrored the 
curricular one she was assuming. It has since been uni- 
versally acknowledged that the revised first year of the 



new curriculum made the academic load that Harvard 
medical students traditionally shoulder heavier than 
ever. That's partly because of new course requirements 
and partly because the coursework covered during the 
first two years of classroom instruction needed to fit 
into a shorter timeframe. For the Class of 2010, the cKn- 
ical clerkship, radically remade in the new curriculum, 
will begin in May rather than July of their third year. 
The reforms also recast the old courses, redistributing 
their content and rearranging the order in which the 
content is presented. 

The sifting and winnowing being done at HMS aims 
to produce a curriculum that better prepares student 
doctors to meet the needs of today's patients. It may also 
provide the seed for a new generation of medical educa- 
tion reforms that wiU take root throughout the country. 

Form Follows Function 



In September 2001, the HMS Faculty Council convened 
its first meeting of the academic year. The rainy weath- 
er outside matched the somber mood indoors, as Joseph 
Martin, then dean of the School, requested a moment of 



Building a Better Doctor at HMS: The First 225 Years 



1782 



LEAN MACHINE: 

The Harvard Corporation 
approved a proposal to offer 
instruction in medicine. One 
year later, the Medical Institu- 
tion of Harvard University 
inducted John Warren, Ben- 
jamin Waterhouse, and Aaron 
Dexter as its first professors. 
Their teaching tools included a 
microscope, a human skeleton, 
and a set of human veins and 
arteries pumped up with wax. 



30 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 





1866 



PAY IT FORWARD: 

Upon receiving an appoint- 
ment as an assistant professor 
of anatomy, David Cheever, 
Class of 1 858, began his 
tenure as an instructor to the 
School's aspiring physicians. 
Reflecting on these years, 
Cheever complained, "Any 
fool could attend lectures, and 
some fools could get a Degree." 
Despite great advances in 
surgery, anesthesia, and 



silence for those who had died in the recent terrorist 
attacks. Council members then got down to business. 
Martin announced that the School would be taking a 
prolonged look at itself in preparation for an accredita- 
tion visit, almost two years away, by the national Liai- 
son Committee on Medical Education. 

Nine internal study committees set about dissecting 
every aspect of the School's operation. Before members 
of the accreditation committee had even made their 
travel arrangements to Boston, the self-review had 
uncovered a key shortcoming: the quahty of the clinical 
clerkships was uneven. 

Many were excellent, the committee found. "What 
was problematic," says Jules Dienstag, dean for medical 
education, "was how medicine itself had changed." 
Treatment breakthroughs coupled with managed care 
had cut hospital admissions and lengths-of-stay. Since 
their development almost a century ago, the clerkships 
had placed students in hospitals. Yet as working physi- 
cians know, hospitals are no longer the best places 
to witness the evolution of a patient's illness. Also, 
because the programs were designed to introduce stu- 
dents to different specialties by rotating the students 
through teaching hospitals, the clerkships didn't allow 
students an opportunity to build long-term clinical 
care relationships with patients. For that matter, they 
didn't spend much time with the School's faculty; in 
hospitals, residents do most of the teaching. 

"The faculty and the students had become more and 
more isolated from one another," says George Thibault '69, 
director of the Academy at Harvard Medical School, an 
organization founded to improve the School's teaching. 



"Any fool could attend 

lectures [at Harvard 

Medical School], and some 

fools could get a Degree." 



medicine, the School was aca- 
demically lax, with few admis- 
sion requirements, no written 
exams, and only four months 
of formal instruction per year. 
The program's curriculum was 
inconsistent, and its appren- 
tice system was dogged by 
rumors of favoritism. Histories 
of the time suggest that the 
institution bordered on being 
a diploma mill. 



"The pressure on the faculty to do clinical care and 
research was rupturing the teacher-student bond." 

In addition to reviewing the need to revise the 
clerkships, Thibault says, the School's self- assessment 
identified a pervasive lack of integration within the 
curriculum. Professors described courses as silos, each 
standing alone, with instructors not knowing the con- 
tents of their peers' courses. And students groused that 
some courses were dishing out second helpings of 
material they'd studied previously. Establishing an 
integrated curriculum would also be vital to bridging 
the gulf between the first two years of basic science and 
the second two years of clinical instruction; with no 
immediate application, students would forget some of 
the science from their classroom work by the time their 
clerkships began. 

While the directors of the various courses mapped 
out the curriculum for the first and second years, says 
Dienstag, "The faculty did something they'd never done 
before; They got together to coordinate what they 
taught. In the past, even people teaching the same 
course didn't necessarily compare notes." 

It wasn't always that way. Ronald Arky a professor of 
medicine who has taught at HMS for more than four 
decades, recalls some flirtations the School has had 
with integration throughout his tenure. But success 
breeds complacency, which in turn breeds institutional 
amnesia, says Arky, and as HMS continued to top 
national rankings as a sterling example of medical edu- 
cation, the benefits of faculty communication were for- 
gotten. The curriculum reform seems to be jogging that 
institutional memory. 




1870 



RAMPING UP: A year after 
becoming president of Harvard, 
Charles Eliot began pushing 
through a number of controver- 
sial reforms at HMS: Admissions 
standards were raised, written 
exams and passing grades 
were required, new depart- 
ments of basic and clinical sci- 
ences were established, a three- 
year degree program was intro- 
duced, and the apprenticeship 
system was eliminated. 




1901 



FRESH APPROACH: By the 

turn of the twentieth century, 
students applying for admis- 
sion to the School were 
required to have an under- 
graduate degree. After much 
prodding by Eliot, the School 
required four years of course- 
work and reorganized its cur- 
riculum into what he had 
proposed as an "efficient 
graded course of instruction 
and examination." 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 31 



Striking a Balance 

One force behind the curriculum reform has been the 
observation that everytliing from doctors' biases to the 
way health care is financed has a direct effect on how, or 
even whether, patients receive care. To help compen- 
sate, tutorials are now introducing students to the 
concept of culturally competent care; they address the 
concern that preconceived notions about a patient's 
race, class, age, sexual orientation, or even health habits 
can skew the care that doctors deliver. 

In the first year of the program, dubbed the New 
Integrated Curriculum, making a better doctor also 
means connecting the science of medicine with the 
sociology of medicine. Courses that had once been elec- 
tives — such as medical ethics and social medicine — are 
now required. These courses further the integration 
concept by exploring the ethical and cultural aspects of 
some of the basic science that other courses present. 

"I found it shocking that previous classes weren't 
required to study ethics," says Peter "Rocky" Samuel '10, 
who sat on a committee of students, faculty, and admin- 
istrators that met regularly to take the pulse of the new 
curriculum as the school year unfolded. "I was blown 
away by all the possible dilemmas out there, the many 
ways that ethics affect physicians' professional lives." 

One case study posited a situation in which a new- 
born was en route to a hospital and in need of life-sus- 
taining extracorporeal membrane oxygenation, or 
ECMO. The hospital's three ECMO machines were in 
use. Should the staff turn away the newcomer or 
remove one of the babies already hooked up? 

"The idea that you might be forced to make such 
decisions was new to many of us," Samuel says. "We go 



1930 




BRIDGE THE GAP: 

As new approaches to evaluat- 
ing students took hold at HMS, 
Francis Rackemann, Class of 




1912, noted, "Correlation 
became the keynote. Since 
then, such broad questions as 
'Discuss milk,' 'Discuss jaun- 
dice,' or 'Discuss the functions 
of the blood' aim to test the stu- 
dent's ability to correlate nor- 
mal structure and function with 
the causes, mechanisms, and 
symptoms of disease." The 
trend toward a more practical 
approach to medical education 
accelerated during the 1 930s. 



to medical school to learn to give treatment, not to take 
it away." After the instructor presented the percentages 
of survival, on and off the machine, for all four babies, 
the students weighed the various options — and found 
themselves disagreeing with one another. By presenting 
the reahty of care rationing so starkly, the exercise 
forced the students to hone their ethical arguments. 

"It may be satisfying to say, 1 like Choice A because 
it's the right choice ethically,' " Davis says. "But if you're 
going to advocate for a particular position, you must 
have some baseline understanding of the ethical imph- 
cations of that position." 

Course Corrections 



Curriculum reform is an organic creature, one that 
evolves as circumstances change. Any number of need- 
ed tweaks became apparent after the inaugural year. 
The frenzied pace of the courses, for example, left 
many students sleepless in Boston. "My sleeping 
schedule certainly was curbed this past year," Davis 
says. "And I'm saying that as someone who used to 
work long hours billing clients in six-minute incre- 
ments." By the end of the first semester, and certainly 
by the second semester, though, the students had 
adjusted to the intensive curriculum and learned how 
to manage their time. 

Other student concerns centered on specific courses 
they felt lacked structure or assumed a level of scientif- 
ic knowledge they hadn't yet acquired. "I was learning 
random facts that might help me compete on 'Jeopardy!' 
but I couldn't imagine how they were going to 
help me become 



a clinician," says 



1947 



"Probably half of what you 

know is no longer true. This 

troubles me, but what troubles 

me more is that I don't know 

which half it is." 



BY HALF: 

C. Sidney Burwell '19, 
dean of Harvard Medical 
School from 1935 to 1949, 
told a group of Harvard 
alumni, "The rate and magni- 
tude of change [in medicine] 
is such that the contents of 
a medical student, like the 
contents of a textbook, are 
partly out of date at the time 
of publication. Indeed, I've 
made a little speech to fourth 
year students that runs like 




32 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 




arvard Medical School has averaged one 
two decades since the Eisenhower era. 



Davis. Those problem classes will be reworked, admin- 
istrators vow, a promise reflected in the role of the com- 
mittee on which Samuel serves. "The administration," 
he says, "has monitored the class's experience every 
step of the way." 

Despite the added work that the new courses entail, 
early returns on the reformed first year are encouraging. 
The old curriculum's course on clinical epidemiology, for 
example, had drawn poor student ratings year in and 
year out, according to Dienstag. Yet its reconfigured suc- 
cessor has earned enthusiastic reviews. 

Call to Order 



A greater integration of second-year course material hopes 
to prompt similar raves from the students. "A morning 
presentation on the changes in respiratory and lung phys- 
iology," Arky says, "is now followed in the afternoon by 
one on a drug-resistant tuberculosis epidemic in Russia. 
We've never had that sort of coordination before." 

Second-year pathophysiology exemplified the old cur- 
riculum's failure to integrate topics. Students studying 
the gastrointestinal system, for instance, could ponder 
the case of a patient with chest pain, yet fail to consid- 
er that the person might be having a heart attack: 
We're studying Gl, not the heart, rights The new curriculum 



remakes pathophysiology into the yearlong Human 
Systems course, in which instructors in the different 
specialties wUl cultivate those connections. 

The reformed curriculum also rejiggers the order of 
instruction. A key example: Pharmacology, taught over 
five weeks in the first year of the old curriculum, becomes 
a two-week block kicking off the second year. Follow-up 
courses in Human Systems will build on the pharmaco- 
logical principles the students have learned. Delaying 
pharmacology until the second year is based on a simple 
premise: Students find it easier to learn about disease- 
curing drugs if they know something about the disease. 

Human development — the changes that are neces- 
sary to a person's healthy maturation — used to be scat- 
tered among different classes; the curriculum now has 
a full course on the subject in the second year. And in a 
change affecting both the first and second years of edu- 
cation, tutorials have been revamped to grow progres- 
sively more challenging, reflecting students' advancing 
knowledge and skills. 

Everything Old Is New Again 

HMS has averaged one curricular makeover roughly every 

two decades since the Eisenhower era. 

The last overhaul, the New Pathway of 



1962 



mi^ssi-f^^mn 



"The best synonym for 

education is growth. Training, 

on the other hand, is something 

that one can do to seals, 

to dogs, and — alas! — to 

medical students." 



this: 'Your teachers have 
tried to give you a good 
opportunity to learn and to 
offer you information v/hich 
the evidence indicated to 
be accurate. Nevertheless, 
probably half of what you 
knov/ is no longer true. This 
troubles me, but v/hat trou- 
bles me more is that I don't 
know which half it is.'" 



FACTS AND FIDO: 

George Berry, dean of HMS 
from 1 949 to 1 965, wrote of 
the need to create for medical 
students "greater learning 
opportunities, a greater 
chance to ask questions, and 
a greater freedom to pursue 
them." Defending these 
changes, Berry explained: 
"Basically, we are dealing with 
the difference between educa- 
tion and training. The best syn- 
onym for education is growth. 



Training, on the other hand, 
is something that one can do 
to seals, to dogs, and — 
alas! — to medical students. 
Training is the acquisition 
of factual knowledge and 
techniques. As these 
increase, training demands 
encyclopedic memorization, 
a requirement that can blot 
out education." 




SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



33 



the mid'1980s, wrought major changes in the first two 
years of medical education, with a tutorial- centered, 
case-based program replacing the lecture-heavy curricu- 
lum. Almost all of these reform eEorts have shared one 
constant: to better mesh what's taught in the classroom 
with what's taught in the hospitals. 

It's not as balanced an equation as it might seem. 
Patient care and research have long outranked the class- 
room in Boston. In addition, teaching stipends for the 
School's hospital-based doctors have varied tremendous- 
ly. "Many faculty members didn't even receive remunera- 
tion," Thibault says. "And those who did receive pay did 
so because of a patchwork quHt of arrangements that 
weren't transparent, weren't equitable, and had huge 
holes." Although hospital-based faculty members are 
expected to spend a certain amount of time teaching, 
some refuse to do so, forcing others to take up the slack. 

So, with changes slated to improve the curriculum, 
the School also decided to cast a critical eye on how it 
rewarded its faculty. This resulted in a plan to trans- 
form the Incredible Shrinking Teacher — the teacher- 
physician whose pay and prestige are often only slivers 
of those awarded peers in clinical care — into an appre- 
ciated, well- compensated one. It is a shift that could 
determine how the new curriculum fares. 

"Faculty improvement is inexorably linked with the 
success of this curriculum," says Thibault, which helps 
explain why Joseph Martin negotiated an agreement 
between the School and its affiliated teaching 
hospitals to increase substantially the level of compensa- 
tion for doctors who teach. In addition, a new faculty 
promotion sys- ^ ^ 

"The theme of our 
conversations in the gathering 
darkness of the autumn after- 
noons was that we expected to 
be brain-dead by spring." 



1966 




tem is being implemented, aimed at giving faculty more 
credit for teaching and pedagogical scholarship. And 
letters of commendation are being sent to teachers who 
scored the highest in student evaluations. 

For those teachers whose evaluations attest to a less 
than stellar performance, notices will be sent offering 
remedial help through the new Academy Center for 
Teaching and Learning. Such coaching will be required 
once the School has sufficient staff to provide it. 

Valuable Perspective 

Faculty members who excel at teaching will play a sig- 
nificant role in the Principal Clinical Experience 
(PCE), a revamped clerkship tailored to the cultures of 
the various teaching hospitals. Student volunteers have 
road-tested pilot versions at several Harvard- affiliated 
institutions — Cambridge Hospital, Beth Israel Dea- 
coness Medical Center, Brigham and Women's Hospi- 
tal, and Massachusetts General Hospital. 

Aside from the earher May start, the key difference 
from the old clerkships is that the PCEs place students in 
one hospital for the entire year as they study aU the spe- 
cialties. This gives students a longitudinal experience, 
allowing them to work with the same patients and to 
witness those patients' iUnesses in various stages. It also 
provides the opportunity to work vwth the same faculty 
members for a year, portending improvements in every- 
thing from faculty mentoring to student assessments. 

Beginning in the spring of 2008, all students will 
undertake a PCE. If the responses to the pilot programs 
are any indication, the new PCE concept will be a hit; In 
2006, a majority of the third-year class, 107 students, 
volunteered for 68 slots. 



1985 



STUDENT UNION: 

For the first time in the School's 
history, students led a curricu- 
lum rebellion in response to 



the passivity that the tedious 
lectures engendered. "We 
began meeting in the fall of 
1965," William Ira Bennett 
'68 says. "The theme of our 
conversations in the gathering 
darkness of the autumn after- 
noons was that we expected 
to be brain-dead by spring." 
About two dozen second-year 
students from the Class of 
1968 succeeded in gaining 
changes that replaced lectures 



with guided readings, inde- 
pendent study, and small 
group discussions. A faculty 
committee eventually intro- 
duced a coordinated interde- 
partmental core curriculum 
that required less memoriza- 
tion of facts. 




EXTREME MAKEOVER: 

HMS inaugurated the New 
Pathway, a curriculum centered 




HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



ompared to their peers in traditional clerkships, 
more confidence in their clinical skills. 



And their enthusiasm is not misplaced. A recent study 
found that students undertaking the first PCE — at Cam- 
bridge Hospital — did at least as well, if not better, on 
Harvard and national board measures of knowledge and 
skills. Perhaps more notably, compared to their peers in 
traditional clerkships, students in integrated clerkships 
reported more confidence in their chnical skills, more sat- 
isfaction with their experiences, a better ability to inte- 
grate basic science and clinical medicine, a better appre- 
ciation of their own strengths and weaknesses, a better 
understanding of how social context affects patients, and 
less of the degradation of ideahsm that occurs typically 
during the clerkship year. 

Changing the Subject 

HMS is mindful of the greater impact of its curriculum 
reform. Dienstag recently attended a conference for med- 
ical education deans from peer medical schools as well as 
for leaders from several premedical programs. The deans 
talked of curriculum reforms at their institutions; the lat- 
ter, how they were improving the teaching of science 
courses to students interested in medical school. "As a 
group," says Dienstag, "we plan to recommend changes 
in premedical requirements to meet the needs of twenty- 
first-century medical schools and medicine." 



The group members agreed that undergraduate 
schools must place a greater emphasis on multidiscipH- 
nary courses that focus on more biologically relevant 
teaching of the sciences that underlie medicine. "Students 
are exposed to a great deal of material that is irrelevant in 
their preparation for the study of medicine," says Dien- 
stag. "Take general chemistry and organic chemistry, for 
example. Premedical students spend a lot of time on these 
subjects, but a substantial proportion of the material is 
not relevant to the study of biology or medicine. What 
is needed is a continuum of general chemistry and organ- 
ic chemistry that prepares students for concepts in bio- 
chemistry." If students are better prepared in biochem- 
istry before entering medical school, he adds, then the 
medical school faculty can spend less time and effort on 
remediation, begin on a higher plateau, and bring students 
to a higher level of understanding and sophistication. 

Dienstag notes a reahty that outside observers readily 
concede: Harvard's cachet means its reforms will be scru- 
tinized and possibly emulated by other medical schools. 
"We have a grave responsibHity not to make too many 
mistakes," he says. "Fortunately, our standards are high; 
this is a very introspective place that's never satisfied." ■ 

Rich Barlow is a freelance writer who lives in Can\hridge, 
Massachusetts. 




on problem-based tutorials, 
during the first two years of 
medical school and clinical 
experience during the tradi- 
tionally preclinical years. The 
new program, which focused 
on a learning style that 
engaged students more fully, 
influenced medical education 
throughout the nation. 



2007 



PROGRESSIVE AGENDA: 

The School assessed the 
success of the first academic 
year of the New Integrated 
Curriculum, which hod its gen- 
esis in a comprehensive self- 
review that began in 2001 . 
The reform calls for content to 
be better integrated, tutorials 
to reflect students' progressive 
accumulation of knowledge, 
and fragmentary, sequential 
clerkships to be replaced 
with longitudinal ones. 




SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



35 




STRESS TEST: As initiates of the 
School's new curriculum, Ishoni 
Gonguli and her classmates 
experienced all its trials, tribu- 
lations, and triumphs. 



SPECIAL REPORT 



DESIGN FOR HEALING 




A first-year student navigates her way through 

a new curriculum and finds more promise 
than pitfalls, hy Ishani Ganguli 



1 




essons 



SKIPPED OUT EARLY ON MY FIRST DAY OF HARVARD MEDICAL SCHOOL. 

In a textbook demonstration of noncompliance, I had failed to meet 
my deadline for filling out the School's required medical forms. As 
I hoisted myself onto the exam table for my last-minute physical, I 
thought about what else would be required of me. That morning I had 
heard presentations about altruism, about the enormous responsibil- 
ities I would be taking on, and about the sacrifices I would need to 
make to become worthy of the doctor's white coat. Yet what I want- 
ed to know most was how four years of schooling would get me from 
where I was — sitting on an exam table— to where I needed to be — 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN I 37 



lis New Integrated Curriculum — five years 
ad more than -)i'v 

making; — would drasticaliv curtail nantime 



y curtail naptime. 



standing beside the table, with at least some degree 
of competence. 

If medical schools took out newspaper ads to lure 
applicants, Harvard's would have read "Shiny new cur- 
riculum, some assembly required." Last fall, as one of 
166 members of the Class of 2010, 1 became part of the 
first group to participate in Harvard Medical School's 
latest major curriculum reform. The architects of the 
reform had placed the freshly integrated program on 
the table and were watching anxiously as we picked 
apart the offerings. 

In the rose-tinted memory of the previous class, first 
year had been filled Mdth free time. My class, though, 
would be spending our afternoons integrating our 
knowledge vertically, horizontally, diagonally, and 
every other way imaginable. This New Integrated 
Curriculum — five years and more than 350 faculty 
members in the making — would drastically curtail 
afternoon naptime. But I knew Harvard's brand of edu- 
cational innovation would come with costs. And once 
the training wheels came off, making the coimections 
for myself in the classroom and with patients would be 
well worth the effort. 

All Together Now 

On the second day of medical school, we donned our 
iconic short white coats, then spent the next few weeks 
trying to make sense of that new outerwear. A freshly 
minted two-week course, Introduction to the Profes- 
sion, provided a whirlwind tour of our future careers. 
After training sessions in basic life support and conver- 
sations with hospital patients, we would participate in 
prescribed reflection sessions — which could be ten stu- 
dents sitting around a conference table, nearly 200 stu- 
dents gathered in an amphitheater, or a lone student 
hunched over a laptop, typing the required daily journal 
entry — to process our thoughts and file them away for 
reference during the coming year. 

In those early weeks we were thrown into integrated 
experiences before we had much to integrate. It was a 
testament, perhaps, to the degree of uncertainty and best 
guessing we'd inevitably face in our careers. 

One afternoon in that introductory period, as four 
classmates and I waited for Stan, our patient-simulation 



38 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



mannequin, to activate, I silently reviewed the contents 
of my laughably limited medical toolbox. Just then, in 
an Indian accent suspiciously reminiscent of that of the 
instructor who had stepped behind a curtain moments 
earher, Stan informed us that he was having trouble 
breathing. Emboldened by the patient's plastic compo- 
sition, I manned his vital-signs monitor while other 
team members teased out his medical history and began 
making sense of his case. I found myself drawing on 
vocabulary I'd picked up from the previous week's tele- 
vision hospital dramas, doing my best impressions of 
Doctors House and Grey. 

This particular rendition of Stan was Mr. S., an older 
man who smoked. We wanted to know what had 
brought him to his current condition. With earnest 
urgency, we requested chest x-rays and pulmonary con- 
sults from another instructor, who was acting as the 
nurse. We later learned that "stat" is a term better 
reserved for dire situations. 

After a marginally successful tracheotomy and several 
unnecessary proddings, we diagnosed Mr. S. with a pneu- 
mothorax — conveniently, the one condition we'd learned 
about that morning — and gave instructions for sending 
him off for the appropriate procedures. Playing doctor 
was a heady experience, but I looked forward to the day 
when I could make cormections between symptoms and 
diagnosis, social history and epidemiology, on my own. 

From Peptides to Patients 

As Introduction to the Profession — our honeymoon 
with medical training — came to an end, we braced for 
the drearier reahties of a true medical school workload. 
Once we got to the familiar topics of biochemistry and, 
later, genetics and physiology, the clinic sessions were 
what cormected the dots for us, bringing together the 
key lecture points we had come to hold sacred with 
patients who had the relevant iUnesses. 

One professor followed up his talk on the biochem- 
istry of Alzheimer's disease with a visit with one of his 
patients, a mustached older man with a dry "wdt. Our 
professor would gently prompt his patient to memorize 
a phrase such as "blue Toyota"; minutes later we'd watch 
as the phrase almost perceptibly vanished from the maris 
memory. This striking demonstration of the power of 




STORIES TO TELL: Critical responses from Ganguli and her peers helped the curriculum designers tweak the ne^v 
courses, both to improve their focus and acknov/ledge the students' different learning styles. 



beta amyloid plaques would stay with me far longer 
than any recollection of their molecular mechanisms. 
Done right, these sessions brought together hard facts 
and humanism with an easy grace. And now we knew 
what we were integrating. 

By the time we began anatomy, we'd had a chance to 
get our bearings in medical school. Even so, like gener- 
ations before me, I was ill prepared for the first sight of 
my cadaver. With its skin flayed and yellow globules of 
fat scraped off to reveal the chest muscles below, the 
cadaver was hopelessly dissociated from my previously 
microscopic view of the human body, gleaned from bio- 
chemistry. At the same time, it was uncomfortably close 
to my sense of my own body. This was a rite of passage 
particular to our professional training, but there was 
little time to savor its surreahty. 



Gross anatomy was not our sole pursuit during those 
seven weeks of the course; lectures, tutorials, and labs on 
the subject were interspersed with others on radiology, 
histology, and embryology. On any given day, we'd be 
charged with identifying such objects as a mechanical 
panda on what we hoped was a purely instructive CT 
scan, an acinar gland under a microscope, or a recurrent 
laryngeal nerve on our cadaver. Days were long and 
smelly, and classmates and I learned the hard way — from 
the dirty looks of second years — that cadaver-scented 
scrubs weren't welcome at lunchtime talks. 

I was faced with learning not only the location of 
different organs and the connections of various blood 
vessels but also the clumsy yet logical language of 
anatomy. I found myself playing with my newly 
acquired vocabulary, finding anastamosed roadways in 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



39 




GETTING TO KNOW YOU: James Gordon and Nancy Oriol v/ere among the faculty >vho introduced first-year students 
to the many aspects of the medical profession during the new curriculum's two-week overvie>v course. 



downtown Boston and ectopic innuendo in conversa- 
tions with friends. 

Toward the end of the course, my tutorial group 
accompanied our leader to a morbidity and mortality 
meeting at Beth Israel Deaconess Medical Center. As 
we arrived at 7;30 in the morning, half-asleep residents 
and interns lined the back wall of the meeting room, 
barely revived by the free watered-down coffee and 
mini-bagels. An attending wearily trekked to the podi- 
um to present the first case, and as she brought up 
radiology and histology images of her late patient's 
tumors to re-create the path to his demise, I had anoth- 
er moment of clarity: This was how it all came together. 
Integrating information across disciplines was not just 
a strategy taught in the classroom, but our eventual 
goal as full-fledged doctors. 



Body and Soul 

With classes that had been electives now mandatory in 
the curriculum, we were given more dots to connect. In 
the medical ethics course each Thursday afternoon, my 
classmates and I would sit in a kindergarten-style circle 
of chairs and argue about end-of-life care or treatment 
rationing during pandemics, drawing on the week's 
readings as much as on our own convictions. There 
were no easy answers, but even if we left each session 
more uncertain than we'd started, we were learning to 
make difficult choices, a skill that would help prepare 
us for the ethical challenges we'd eventually face. 

In the spring, ethics made way for social medicine. 
Once a week we were invited into the tight-knit global 
health community in which Paul Farmer '90 and Jim 



40 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



1 



LV^OV^ -J-Q 


.iimh^ 



mteractions with Stan the simulator. 



Kim '91 would finish each other's sentences and engage 
us with tales of bureaucratic hurdles, drug thefts, and 
multiply resistant tuberculosis. 

Nearly every week, we were confronted with figures 
and images of insurmountable health needs in develop- 
ing countries and asked how we'd tackle those prob- 
lems. Presented with the substantial accomplishments 
of our professors and the similar efforts of many of our 
classmates in the field, it was hard to avoid the moral 
elephant in the lecture hall — a seeming imperative to 
devote our careers to global health. But what if our 
medical interests or skills led us elsewhere? At one 
point Kim took a moment to absolve us of any obliga- 
tion to go into global health. Whatever our career 
goals, this course provided us yet another way to create 
a context for medicine and to draw connections 
between patients and science. 

Squeezing It All In 

With our requirements more numerous and our time 
more structured than that of previous classes, we 
turned to technology for assistance. Virtual histology 
tools allowed us to zoom in on individual nuclei, while 
streaming lecture videos gave us the option of watching 
a presentation at multiples of its original tempo. We 
dubbed this "2x-ing" or, on a good day, "2.5x-ing." On 
any given evening, society rooms were populated with 
first years, their ears cupped by clunky black head- 
phones, watching that day's lecturers gesticulate in car- 
toonish frenzy. 

Those same professors would nervously monitor our 
lecture attendance and our online evaluations of them. In 
a teasing voice. Farmer told our class he was afraid of 
us — ^but he wasn't entirely joking. As the test cases for 
the new curriculum, we were primed to be critical — it 
was easy to spot the flaws when we were expecting 
them — and the faculty encouraged candor. Courses such 
as The Role of Discovery in Medicine — a newly crafted 
month-long class meant to motivate our travels between 
bench and bedside — generated particularly unfavorable 
feedback sessions, and anonymous online forums gave 
credence to curriculum designers' anxieties. 

It was certainly no simple task to cater to more than 
160 medical students with idiosyncratic learning styles 



and divergent academic expectations. Some of my 
classmates yearned to do meaningful work overseas, 
while others savored each moment spent with their 
pathology textbooks. And we had less time to explore 
our interests. But true to the Harvard system, evidence- 
based changes were made in real time in an effort to 
appease the majority. At the drop of a feedback session, 
class schedules shifted and physiology quizzes svwtched 
from in-class to take-home. 

By the end of first year, we'd been hit with as many 
integrated experiences as our professors could devise 
names for, from focused exercises to integrated case 
reviews to the particularly ambitious clinical-pathologi- 
cal-microbiological conferences. But the true test of the 
curriculum's success was our growing abihty to make 
the connections organically, and for ourselves. 

One spring day, a lecture on HIV treatment options 
followed one on the cellular biology of HIV invasion. 
That afternoon, we met a patient I'll call Rita, an HIV- 
infected African American woman in her early forties 
whose illness had visibly aged her. She sat in a chair that 
faced the small classroom and told us her story, her some- 
times garbled words tumbling out of her mouth as if 
she had no power or desire to curb them. 

I wondered which drugs she was taking, and how dif- 
ficult it was for her to adhere to the comphcated regimen. 
How had her body responded to the infection given her 
genetic makeup, and what would that response mean for 
her son, who also carried the virus? How had her experi- 
ences led her to educate others about the disease with 
such humor and flair? 

Hands shot up in the small classroom that afternoon, 
propelled by lessons learned that morning and through- 
out the year. Talking with Rita about these issues was a 
far cry from our initial bumbling interactions vvdth Stan 
the simulator, and the reasons for this went well beyond 
the fact that Rita was not fashioned out of plastic. This 
time, we were asking our own questions, connecting the 
dots for ourselves. Our hours spent poring over books 
and bodies converged in the guise of this small, earnest 
woman. Rita saw educating as her moral imperative. It 
was ours, then, to learn. ■ 

Ishani Ganguli 10 worked as a staff writer for The Scientist 
before matriculating at Harvard Medical School. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 41 



SPECIAL REPORT 



DESIGN FOR HEALING 



An innovative clerkship immerses third years 
in chnical care, introducing them to medicine and, often, 
to themselves, hy Ann Marie Menting 



earnm 



E PALED SLIGHTLY. IT WAS NEARLY IMPERCEPTIBLE, JUST AN 



because his eyes had changed, too, a sUght distance slipped into what 
had been a bright and engaged gaze. And while the torrent of conversa- 



tion continued, 



carried a film of pause. 



"It was one of the strongest relationships I've had with a patient," 
say Liang '09. "Of course, that made it much more difficult when she 
passed away." 

Confronting the death of a patient is rarely easy for a physician, but 
for a medical student — fresh to the daily drama of the heaUng pro- 
fession — it can imprint deeply Students are often left alone to work 



42 I HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



TAKING THE LONGER VIEW: 

The longitudinal clerkship 

program at Cambridge 

Hospital gets high marks 

from participants such 

as Peter Liang. 




43 



le challenge was to establish continuity as the 
that emphasized a longitudinal approach. 



through the sadness, frustration, and fear of such a loss. 
Or they seek support from peers who are groping their 
way through the same experience. But Liang and the 
other third-year students in the Harvard Medical 
School-Cambridge Integrated Clerkship (CIC) have a 
support network of preceptors, administrators, and 
staff physicians that is wide, deep, and so invested in 
mentoring that the students' traumas and triumphs are 
shared. The CIC builds community, an extended family, 
whose members are committed to — and even thrilled 
by — the practice of effective, humanistic medicine. 

All the Difference 



Liang had met the elderly woman, we'll call her Betty, in 
an early medicine clinic he had attended as one of 
eleven third-year students in the past year's CIC. His 
preceptor had thought Betty would be a good patient 
for Liang to follow; her diabetes, dialysis, and end-stage 
renal disease would challenge him, as would the unex- 
pected medical issues that were bound to crop up. 

"I knew her history was complex," Liang says, "but 
when we met, her primary complaint was severe cramp- 
ing." Betty had also developed diarrhea — a condition 
that prompted her to stop going to her dialysis sessions. 

"I researched the side effects of her medications and 
found that what she was taking for cramps could cause 
diarrhea. I told my preceptor what I had found, and we 
stopped the medication." 

Betty's bout with diarrhea ended; Liang had helped 
her overcome a problem that, while not medically as seri- 
ous as her other problems, had been important to her. 

"It drew us together," Liang says. "Betty seemed to 
trust me more. It was encouraging to be able to help her 
in a real way." 

Establishing relationships that allow students to 
address their patients' medical needs, both grand and 
humble, is an integral objective of the CIC, a 12-month 
immersion in core clinical medicine for the School's 
third-year students. The program replaces the tradition- 
al sequential clerkship model with a longitudinal experi- 
ence that emphasizes progressive professional and per- 
sonal development. 

Conceived of as a complete redesign of the principal 
clinical year, this innovative clerkship brings small bands 
of the School's third-year students into the only pubhc 



health care system affiliated with Harvard Medical 
School — and into the heart of contemporary health care. 
Working and learning together under the guidance of 
attending physicians, the students are schooled in the art 
of doctoring in a way that, untH recently, was considered 
too cumbersome and costly to implement. But early 
returns show it may be one of the better methods for 
buildtng a new doctor, one ready to meet the challenges 
of chnical medicine in the twenty-first century. 

In with the New 



The third year of HMS usually finds students migrating 
from hospital to hospital for stints in a range of medical 
specialties. Every few weeks, the students move to a 
new clinical venue, a peripatetic educational experi- 
ence that often stymies their efforts to establish sub- 
stantive relationships with faculty and patients. This 
fragmented sequential model also presents obstacles to 
School faculty, making it difficult — perhaps even unap- 
pealing — to integrate the different learning experi- 
ences they offer students. 

When HMS faculty and administrators began dehb- 
erating the contents of the School's curriculum reform, 
they placed the revamping of the principal chnical expe- 
rience high on their project hst. This urgency was in 
large part spurred by results of an internal evaluation 
that found the School's clerkships needed to be revised 
to better address the changing landscape of medicine 
and health care. 

But it was also nudged by the concern growing 
among faculty, especially those v^thin the Academy at 
HMS, an organization that fosters excellence among 
the School's faculty, that traditional sequential clerk- 
ships no longer produced students who were broadly 
skilled in the core competencies of the many medical 
disciplines. Without a broad skills base, they worried, 
students could not meet the health care needs of 
today's society. 

The challenge, as they saw it, was to establish conti- 
nuity as the organizing principle for a new model of 
clerkship. Developing clerkships that emphasized a lon- 
gitudinal approach would allow medical schools to pro- 
vide a patient- and learner-centered envirormient that 
fostered a continuity of patient care, a continuity of cur- 
riculum, and a continuity of supportive supervision. 



44 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



This challenge was given form by David Hirsh, an 
HMS instructor in medicine, and Barbara Ogur, an assis- 
tant professor of medicine at the School. They crafted an 
integrated clerkship that replaced the traditional rota- 
tion scheme with a yearlong immersion in patient care. 
The CIC, as it quickly was dubbed, launched as a pilot 
program in July 2004. 

Based at Cambridge Hospital, an HMS-affiliated 
teaching hospital that is part of the Cambridge Health 
Alliance regional health care system, the CIC is the 
School's longest running revised clerkship program. 
Since it was piloted, the CIC's longitudinal model has 
been modified and adapted for use by Beth Israel Dea- 
coness Medical Center, Brigham and Women's Hospital, 
and Massachusetts General Hospital. These programs 
are leaping quickly from infancy to adulthood: Beginning 
with the Class of 2010, the new clerkships will be the 
standard third-year experience. 

The CIC pHot hosted eight students who had been 
randomly selected from 18 volunteers of the 189 rising 
third-year HMS students. By July 2007, the Cambridge 
program had berths for 12 students who, thanks to the 
enthusiastic reviews from past participants that have 
boosted the program's popularity, were selected from a 
pool of nearly 30 volunteers. 

In the CIC, students have close, continual contact 
with a panel of patients, serving as their patients' 
health care companions while simultaneously learning 
to become their patients' health caregivers. By navigat- 
ing the system with their patients, the students gain a 
ground-level perspective of the health care system and 
a longitudinal perspective of caregiving. And they 
learn the large and small details of clinical medicine 
from the very staff physicians who provide their 
patients with care in internal medicine, neurology, 
obstetrics/gynecology, pediatrics, and psychiatry. The 
students also are responsible for patients in the radiol- 
ogy and surgery units, with their surgical experience 
augmented by a period of working directly with an 
attending surgeon. 

To develop their chnical skills, the students pair with 
preceptors in each discipline and work in the preceptors' 
respective clinics for five- to ten-hour periods every 
week or two. The process allows the students to aggre- 
gate information and experience over time and under the 
supportive supervision of senior physicians. 




GOT IT COVERED: A young patient at the Cambridge 
Health Alliance's East Cambridge Clinic meets with HMS 
student Liang for follov^-up care for an injury. 



This working and learning relationship firmly places 
each student in partnerships of care for their patients. 
Encouraged to seek resolutions to their patients' med- 
ical issues, the students question and evaluate patient 
diagnoses and treatment plans during rounds, during 
case-based tutorials with peers and preceptors, and 
through investigations of the medical Hterature and self- 
directed learning projects. As Liang found when caring 
for Betty, these collaborations are both medically and 
educationally rewarding. 

"By accompanying our patients on visits with their 
doctors, we're able to understand more what it means to 
be a patient," says Liang. "That helps us appreciate each 
patient as a person rather than just as someone with a 
medical ailment." 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



45 




i 



TEACHABLE MOMENT: Clerkship 

students are encouraged to take 

time 'with their patients so they 

can deliver care that engages, 

teaches, and reassures. 




Gloria Hou '08, another clerkship student, would agree. 
"I have worked with my pediatrics preceptor as she cared 
for patients who are the children of children she took 
care of years ago. She knows their social history, under- 
stands what's going on with the farmly, and feels like it's 
her job to deal with not only their direct medical needs 
but the social aspects of those needs, too. Such experi- 
ences have helped me learn what medicine is really hke." 

Liang's and Hou's observations give credence to the 
fostering of the "professional perspective and reflective 
practice" that CIC creators Ogur and Hirsh describe in 
the goals they set for the program. But building these 
sorts of connections while also fulfilling the academic 
demands of a third-year medical student can take its toll. 

"We were told that our panel of patients would have 
between 70 and 80 people," says William Soares '09, 
another clerkship student. "I naively thought I could get 
to know that number of people well and stiU keep on top 
of a fuU curriculum. But it was incredibly difficult to 
keep up. I now know I must decide which patients are 
important to follow closely and which might not need 
me as much. To serve my patients well, and to do well 
myself, I've learned I have to balance medicine with Me." 

Let's Talk 



Learning to achieve such a balance is a goal that is 
unwritten, but not overlooked, in the CIC structure. 
Nurturing each student's progress and well-being is 
integral to the program and is tended to not only by the 
preceptors but also by Ogur, Hirsh, and the CIC's 
administrator, Wendy Gutterson. 



"Students can come in and talk about anything they 
want — from why they're not getting enough sleep to 
whether they should attend a patient's funeral — and we 
work through their concerns with them," says Gutter- 
son. "This is an incredibly intense and formative year for 
the students so we do what we can to help." 

Most of these conferences occur in a pocket of an 
office situated off a large room in one of the hospital's 
satellite buildings. Ogur, Hirsh, and Gutterson share 
the office; the students share the large room. Coming up 
with this home-away-from-home space for the students 
was not easy — like most urban medical institutions, 
Cambridge Hospital continually confronts space chal- 
lenges — but it was considered essential. 

"Senior management wanted to provide the students 
with a place of their own," says Gutterson. "They worked 
hard to find space and to make the capital investments 
that would give the students a valuable study space and 
a place to gather." That space houses desks and comput- 
ers for the dozen students as well as a Hbrary of shared 
texts, a conference table, and an overhead projection sys- 
tem that the students use to present cases at the weekly 
tutorial sessions. The space also boasts a small kitchen; a 
sofa, handy for catnaps; and several oversized plastic bins 
of munchies. 

The solidarity cultivated in this room benefits not 
only the students but the program, too. "Our conversa- 
tions with the students are critical to the program's 
development," says Gutterson. "For example, their 
comments led us to create a more integrated pediatrics 
learning experience. In addition to following pediatric 
patients to psychiatry chnics, students now learn about 



46 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



;•':-. 



lis led to an innovation that has been 
circles: an electronic notification system. 






developmental issues from a team of physicians from 
pediatrics, psychiatry, and neurology; observe the inter- 
actions of children at local community day care centers; 
and discuss expected and unexpected issues in normal 
development during a tutorial session. Everyone agrees it 
is a stronger educational experience." 

On the Same Page 

This openness to new ways of doing things led to an 
innovation that has been garnering attention in non- 
education circles: an electronic notification system. 
Since CIC students are expected to follow their 
patients on all scheduled visits and, as possible, to con- 
sultations, admissions, deliveries, surgical procedures, 
and rehabilitation visits, there needed to be a process 
for informing them quickly of their patients' peregri- 
nations. So program administrators, together with the 
alliance's information technology group, developed a 
pager system that gleans information from an electron- 
ic registry. 

I The registry integrates the computerized scheduling, 
record keeping, and admissions systems in place 
throughout Cambridge Health Ahiance. Students enroU 
each of their patients in the registry and are then paged 
every time one of those patients keeps an appointment, 
cancels an appointment, shows up in the emergency 
department, or has any other interaction at one of the 
alliance's sites. 

"In traditional clerkships," says Liang, "you know 
exactly when you're going to be in the hospital and for 
how long. We carry our pagers with us at all times and, 
with some exceptions, when I get paged, I'm going to 
answer it. Although I try to make as many of the calls as 
I can, I've learned to balance those calls with my sched- 
uled clinic duties, my study demands, and the time I need 
to spend with other people. Even if the call is not some- 
thing rU go in for, at least I know one of my patients was 
in and why." 

This wealth of patient information generated an 
unexpected consequence; Physicians at Cambridge 
Hospital were eager to be included in the system. So the 
alhance made the notification tool available to practi- 
tioners throughout its hospitals and primary care prac- 
tices, perhaps the first health care group in the nation to 
have this capability. 



High Marks 

The CIC story has representatives from other medical 
schools seeking out the program's administrators. And 
the fact that the program recently brought the aUiance 
the top honor for medical education reform from the 
National Association of Pubhc Hospitals and Health Sys- 
tems should keep those cards and letters coming. 

But to satisfy decision-makers — and themselves — on 
the pedagogic merits of the new approach, Ogur and 
Hirsh teamed with Edward Krupat, director of the 
School's Center for Evaluation, and David Bor '75, chair of 
its Integrated Clerkship Steering Committee, to take an 
empirical look at the achievements of the program's first 
cohort of students. Their findings, presented in the April 
issue of Academic Medicine, were encouraging. 

The CIC students performed at least as well as stu- 
dents in traditional clerkships in tests of content knowl- 
edge and skills, such as the tests issued by the National 
Board of Medical Examiners and the fourth-year 
Objective Structured Clinical Exam. The CIC students 
retained content knowledge better, however, than stu- 
dents in traditional programs, scoring higher on year- 
end measurements of comprehensive clinical skills. 

The CIC students also were more likely than tradi- 
tional clerkship students to see patients before diagnosis 
and after discharge and to receive feedback and mentor- 
ing from experienced faculty. Perhaps best of all, CIC 
students were more satisfied with their curriculum and 
felt better prepared for the challenges of patient care, 
including involving patients in decision-making and 
understanding the social contexts affecting their 
patients. Members of the most recent CIC cohort concur. 

"One of the biggest differences I find when I talk with 
my classmates," says Liang, "is that they feel exhausted 
and even disillusioned with medical school while I feel 
excited and am looking forward to what's next. The pro- 
gram has made a huge difference in my morale and ener- 
gy level — and my attitude." 

"I think this is a humane way to learn medicine," says 
Hou, "one that has allowed me to move forward with my 
idealism very much intact. And that's incredibly impor- 
tant, something test scores just can't capture." ■ 

Ann Marie Meriting is associate editor of the Harvard Medical 
Alumni Bulletin. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



47 



■ ■i'ik-^^: 




SPECIAL REPORT 



DESIGN FOR HEALING 



With their earhest patients made of sihcon anc 
circuitry, Harvard medical students are 
inding it easier to first do no harm, foy Mark Baard 



HE PACKING MATERIAL HAD BARELY BEEN BRUSHED FROM STAN, THE 



firsthand the role that simulated patients could play in presenting 
medical students with realistic clinical challenges. Oriol, dean for 
students at HMS, offered to stage a demonstration of Stan in clini- 
cal crisis. After the group examined the patient and reached a diag- 
nosis, one of them gamely stepped forward to intubate the patient. 
The situation quickly became tense, however, as Stan's tongue 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN I 49 



he physician struggled to guide the tube 
breathiag became iacreasiagly labored. 



and larynx began to swell. The physician, drawn into the 
urgency of the moment, struggled to guide the tube into 
place while his plastic patient's breathing became increas- 
ingly labored. Sweat began to trickle down the physician's 
face; Oriol watched it bead and drop off the tip of his nose. 

"I suddenly remembered the supply of oxygen we 
kept handy for demonstrations," she says, "and decided 
to move closer to it — and to be ready to put it to use. I 
was afraid our simulated patient would have to make 
way for a real one." 

Such an intense reaction to the simulator reveals the 
power of the new teaching tool. "If a simulator can 
engage an experienced physician," says Oriol, who is 
also an HMS associate professor in the anesthesia 
department of Beth Israel Deaconess Medical Center, 
"it can definitely cause students to pay attention. Stu- 
dents find working with the simulators to be a particu- 
larly acute experience because they know they'll likely 
be treating real patients under similar circumstances." 

HMS became one of the first medical schools in the 
nation to make medical mannequins available as a stu- 
dent teaching tool for both basic and clinical science 
when Harvard faculty at the Cambridge-based Center 
for Medical Simulation began offering this leading-edge 
technology to students as early as 1997. But in the cur- 
riculum overhaul that the School introduced this past year, 
all incoming students at HMS will start their education 
working on patients made of silicon and circuitry. To 
make learning as dynamic as a real clinical experience, 
the School is using its lifelike simulators to bring patients' 
cries, medical comphcations, and missed diagnoses into 
the first-year students' introduction to medicine. 

How to Spell Relief 

In the simulation classroom, as in real hospital settings, 
things don't always go smoothly. Doctors — and doctors- 
in-training — make mistakes in the heat of emergency 
care. A constellation of symptoms may mask the underly- 
ing cause of a crisis. A patient's clinical course can change 
suddenly. And patients, including Stan, named for his role 
as standardized patient, can be hard to manage. 

"Novices don't realize how hard it can be to think 
through a diagnosis while they're trying to communicate 
with the patient," say Oriol. "The physician's instinct is 



to want to make patients feel better, but in trying to 
make them feel better, we can also harm them." 

Konstantina Stankovic '99, who encountered Stan 
during her student years, knows firsthand how the 
sounds and readings that Stan and his simulator buddies 
generate can create powerful and emotional learning 
experiences for health care professionals preparing for 
their initial encounters with real patients. 

Stankovic recalls being a member of a team of med- 
ical students who were scrambling to help Stan as he 
cried, "It hurts so much! They said you'd give me some- 
thing for the pain!" 

Her team, working as part of a course organized by 
faculty anesthesiologists John Pawlowski and Martha 
Gallagher, diagnosed a twisted bowel and elected to 
administer a significant dose of morphine for the pain. 
But Stan suddenly stopped breathing. A member of the 
team grabbed an ambu-bag and used it to get Stan breath- 
ing again while another intubated him. His hfe was 
saved — and the reUeved team took a collective deep 
breath. "Working with Stan sharpens your abihty to sort 
through a wealth of information, while dealing with the 
patient's immediate needs," says Stankovic, now an oto- 
laryngologist at the Massachusetts Eye and Ear Infirmary. 

The Family of Stan 

The HMS community's original patient simulator, pur- 
chased in 1993 by a consortium of HMS anesthesia 
chiefs, has become an old-timer in the patient-simula- 
tion business. Even a newer model, housed on the med- 
ical school campus since 2001, is showing signs of wear. 
His tongue has been tattered as a result of countless 
probings by instrument-wielding students. And 
replacement skin is always available to repair an arm 
that has taken too many needle jabs. His looks betray the 
years even more than the worn parts: Stan is a barrel- 
chested fellow, the 1950s masculine ideal — think George 
Reeves playing Superman on television. 

To reduce the demands on Stan and to keep in step 
with evolving technology, additional mannequins have 
been purchased as part of the formation of the G. S. Beck- 
with Gilbert and Katharine S. Gilbert Medical Education 
Program in Medical Simulation at HMS in 2003. With 
the Gilberts' generosity, Stan has been joined by four 



50 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



b 



'^Z 



H^ 




/ 



\ 



'P^-~ 



'Jh:\. 



S*-^ 




STANf THE MAN: James Gordon, 
^ ' director of the Gilbert Program, 
.coaches medical student Jason 
Sanders in listening for his 
patient's breath sounds. 



^ 



identical adult males and an infant simulator. A child 
simulator is also housed in the Gilbert laboratories, as 
part of a long-standing partnership with the Harvard 
anesthesia chiefs at the Cambridge center. 

Currently retailing between $40,000 and $250,000 
each, the recent generation of patient simulators can 
draw upon an extensive repertoire of physical, biochem- 
ical, and verbal responses to the care that students might 
administer. Tongues can swell; airways can alter to sup- 
port, or thwart, endotracheal intubation; and pulses at 
the mannequins' wrists, necks, and groin areas can vary 
or coordinate with the ECG and systoHc blood pressure. 
The simulated patients can support vigorous CPR and 
can accommodate defibrillator paddles, which can be 
placed on metal contacts that dot their chests. The man- 
nequins' pupils can constrict in response to hght, and 
oximeters attached to plastic fingertips convey readings 
to monitors positioned near the simulators' stretchers. 

The baby member of the School's simulator family has 
some extra bells and whistles — and hghts — useful to 
depicting conditions that could distress an infant. When 
he's not in trouble, he hes docile in his bassinet, a chub- 
by infant in a hospital-issued knit cap. His httle belly 
swells with each breath. He blinks, cries, coos, and even 



wets. He is certainly easier to manage than a Hve, squirm- 
ing baby. Yet, like a real infant, the baby simulator can 
turn blue in a twinkling, cueing students to his acute 
need for oxygen. And even though the indigo glow comes 
from a row of tiny bulbs hning the baby's mouth, the 
sight is enough to panic medical students. 

Behind the Green Curtain 



That level of emotional engagement is exactly what 
instructors using the simulators are trying to achieve, 
says James Gordon, director of the Gilbert Program and 
an HMS assistant professor in Massachusetts General 
Hospital's Department of Emergency Medicine. The 
program, which aims to foster experiential learning in a 
no-harm-done environment, oversees the integrated 
full-body simulator laboratories that house the man- 
nequins on campus. The laboratories wed basic and 
clinical science and together can accommodate a class of 
160 students on any day of the year. 

In the laboratories, student-Stan interactions are 
orchestrated off-stage. Hidden from student eyes by a 
curtain, an instructor — who typically doubles as the 
voice of the patient — watches monitors that show the 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



51 








effects that various therapies have on Stan and can deter- 
mine the changes that occur to his vital signs as a result 
of receiving, for example, an injection. With his blinking 
blue eyes, convincing skin texture, and varied voice 
inflections, Stan does his best to dehver the dose of real- 
ity that students need to understand the chnical context 
and to rehearse interactions with patients. 



BREATH OF FRESH AIR: Nancy Oriol, the 
dean for students, introduced the original 
Stan to Harvard Medical School. 



"It's a way of making learning more effective," Gordon 
says of the combination of traditional instruction and 
Web-based information technology that characterizes 
the teaching approach. "Students using the simulators 
integrate and remember the material because of the pow- 
erful way it is presented. Imagine, for example, that Stan 
complains that his chest hurts. As part of the students' 
session with Stan, you can pull up a computer video of an 
angiogram that shows a blocked coronary artery. Bring- 
ing real images into the simulated clinical interaction is 
one way to give students an immediate opportunity to 
integrate relevant anatomy and radiology with the 
patient's clinical problem." 

On a whiteboard above Stan, Gordon draws a dia- 
gram illustrating a circumplex model of emotion, a 
broad representation of human affect that cognitive 
psychologists have described. Students in a lecture hall, 
he says, are often in a deactivated state, which inher- 
ently hmits the power of the lesson. 



Virtual Reality 



The patient mannequins aren't the only form of simulated learn- 
ing that Harvard Medical School students receive. On-screen 
virtual patients, which can be coupled v/ith mannequin-based 
sessions, provide a two-dimensional electronic layer to the 
increasingly varied experience now available to the students. 
While Stan can help students learn how to interview a 
patient in a doctor's office or resuscitate a patient crashing 
in the emergency room, an on-screen patient can simulate 
the long-term care of the same patient with a chronic illness. 
A student might diagnose a virtual patient with diabetes, for 
example, and then visit with that same patient as the disease 
progresses over many years, causing kidney dysfunction and 
heart disease. 



"Medical students and even residents aren't getting as much 
access to real patients as they used to," says Grace Huang, 
an HMS assistant professor of medicine at Beth Israel Dea- 
coness Medical Center (BIDMC). "Simulations expose students 
to conditions they might never see in their residencies." 

Huang is working on the Virtual Patient Project, a program 
at BIDMC that focuses on long-term care and clinical inter- 
actions with patients. So far, she and her colleagues have 
amassed case histories of more than 50 virtual patients who 
exist only on a hard drive. 

"The Virtual Patient Project allows us to give students longi- 
tudinal views of patients," says Huang. "Nine years are com- 
pressed into a single experience." 



52 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



T 



ore than a mannequin and less than 

- methini 

or an ambassador tor medicine. 



But simulations such as those provided by Stan put 
students on alert by generating anxiety and surprise. "As 
often as possible," Gordon says, circling the word "acti- 
vated" on the v^hiteboard, "thaVs where we want to be." 

Oriol has taken great satisfaction in witnessing the 
effect that the simulators can have on student learning. 
When, for example, one of the students from the Class of 
2010 was asked to interview a real patient during 
Patient-Doctor I class, Oriol says, "he did a beautiful job. 
His classmates were blown away. They asked him where 
he had learned how to do that, and he just shrugged and 
said he'd been practicing with the sims." 

Pinch Hitter 



More than a mannequin and less than a robot, Stan also 
has served as something of an ambassador for medicine, 
playing a key role in several programs designed to pre- 
sent high school and college students with an authentic 
medical instruction experience and an opportunity to 
increase their medical literacy. Oriol says that feedback 
from participants in these programs, together with that 
gathered from HMS faculty and students who had expe- 
rience working with Stan, has helped guide the develop- 



ment of a new course for HMS students. Introduction to 
the Profession. Part of the School's revised curriculum, 
the course is now the entry point for each incoming class. 

Oriol has been dehghted with the response of the first 
class to go through the new curriculum. Each member of 
the class experienced ten hours of simulator time by the 
midway point of the first year, beheved to be the most in 
the nation. In addition, says Oriol, "We've estimated that 
about 30 of the 166 members of the Class of 2010 came to 
the simulator labs on a weekly basis during their first 
year," she says. "You have to remember this is voluntary, 
above and beyond what's expected of them." 

That time spent with Stan is becoming more precious 
as shorter rotations and in-patient care shifts mean that 
many medical students might never see an asthma attack 
or a croupy baby before they graduate. 

Simulated patients also help ensure that a real 
patient's heart attack will not be the first one a young 
doctor has ever responded to — or even witnessed. 
"In the simulator lab, we can teach you more, sooner," 
says Gordon. "Here, there's always a patient waiting 
for you." ■ 

Mark Baard is a freelance writer based in Milton, Massachusetts. 



Huang's interns at BIDMC can practice taking down 
patient histories, diagnosing chronic illnesses, and prescribing 
treatments, all while working with screen-based virtual 
patients. If one of the virtual patients becomes sick as a result 
of a missed diagnosis or bad clinical decision, for example, 
the student will get an earful from the patient. A video of 
the patient, portrayed by an actor, will show her after she's 
checked into the hospital, to underscore the potentially serious 
consequences of making a bad call. 

Most of the virtual patients Huang uses are text-based, con- 
sisting of multiple<hoice questionnaires and decision trees. In 
addition, Huang weaves interactive pathophysiology diagrams 
and tutorials into the virtual patient lessons. 



Harvard medical students can also learn from the Human 
Systems Explorer project, created by Michael Parker, an 
HMS assistant professor of medicine. Parker's project draws on 
the full power of the Web — animation, simulation, and interactiv- 
ity — to present students with an accurate portrayal of functioning 
human systems. The computer-based tool layers sophisticated 
computational and mathematical algorithms on the movement 
and sound capabilities inherent to the Web to create realistic 
time-dependent phenomena. The system can, for instance, show 
how the heart's pressure, sounds, and cycle coordinate. And its 
interactivity lets students vary physiological parameters, allowing 
them to change lung volume over the entire physiological range 
while witnessing the forces that result at any given volume. ■ 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



53 




SION 



A pliysici ^m vv^lio co nducts music r e flect s! 



54 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 








MUSIC 



'0 

10 




on the healing powers of min gliTi g the senses, hy S am i ift VVong ^ ] 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 55 




()w miglil wt" liHrnrss lilt* Hssot'ialivt" power of rniisitMiu] 



When Edgar Degas could no longer see well enough to paint, 
he turned to sculpture, relying on a newfound tactile keen- 
ness. When French composer Gabriel Faure's hearing 
became deranged, he cried, "I only hear horrors." Ludwig 
van Beethoven persisted in writing symphonies yet confid- 
ed to his brothers, "I am deaf. . .how would it be possible to 
admit the deficiency of a sense 1 ought to possess to a more 
perfect degree than anybody else?" 



A painter loses his eyesight; a composer 
loses his hearing. How might we treat 
and rehabilitate such patients? How can 
we take advantage of the healing mech- 
anisms of neuroplasticity and sensory 
transfer to lift the spirit of a devastated 
artist? How might we harness the asso- 
ciative power of music and the visual 
arts to amplify one sense so as to replace 
the loss of another? 

I have spent my professional life 
immersed in issues of sight through my 
work as an ophthalmologist and sound 
through my work as a symphony conduc- 
tor. I have enjoyed inhabiting both of 
these worlds, so it is perhaps not too sur- 
prising that I would be captivated by 
thoughts of how their intersection might 
benefit others, particularly people who 
have lost the use of a sensory capacity 
that is vital to their creative expression. 

My interest in exploring these possi- 
bilities has led me to probe the physio- 
logical aspects of synesthesia, a perception 
by one sense, such as vision, through 
stimulation of another sense, such as 
hearing. Could our understanding of 
how the brains of synesthetes — and 
nonsynesthetes — respond to sensory 
stimulations give us clues to therapies 
for those who've lost a perceptual win- 
dow to their worlds? 

Coda Blue 



Synesthesia derives from the Greek terms 
syn, meaning together or with, and acsthe- 



sis, meaning sensation or perception. The 
scientific community became aware of 
this condition in the late 1880s when Sir 
Francis Galton, a half- cousin of Charles 
Darwin, wrote in Nature about individu- 
als who saw colors when viewing letters 
of the alphabet or hearing music. 

Synesthesia can find expression in 
several ways. In music-color synesthesia, 
individuals experience tones or sounds 
in response to colors or shapes. For those 
with ordinal-linguistic personification, 
ordered sequences, such as letters, num- 
bers, days, or months bear distinctive 
personahties: Wednesdays, for example, 
might be perceived as an impish adoles- 
cent. Spatial-sequence synesthetes can 
experience three-dimensional percep- 
tions; months may appear near the 
ground. In the rarest form, lexical-gusta- 
tory, words cause taste sensations in the 
mouth — "echo," for example, may always 
ehcit the taste of buttered toast — ^while 
in the most common form, grapheme- 
color, thought to be experienced by 68 
percent of synesthetes, letters or num- 
bers have identifying colors. 

Although the prevalence of synesthesia 
is imprecisely known, researchers esti- 
mate that, at minimum, it appears in one 
in twenty thousand but that certain types 
manifest in one of every two hundred peo- 
ple. It is a lifelong condition, possibly her- 
itable, and is remarkably consistent: If the 
letter M is perceived to be purple, it will 
always be purple. This latter trait has been 
perhaps most famously expressed by 



Vladimir Nabokov. "In the green group," 
he wrote, "there are alder-leaf j; the unripe 
apple of p, and pistachio t .... In the brown 
group, there are the rich rubbery tone of 
soft g, paler j, and the drab shoelace of k" 

Some musicians strongly associate 
sound with color. For the composer 
Nikolai Rimsky-Korsakov, the key of C 
major was white, while the key of B major ■ 
was a gloomy steel blue. Franz Liszt f 
exhorted an orchestra, "That is a deep 
violet, please, depend on it! Not so rose!" 

Tone Poems 



My interest in synesthesia and the brain 
led me to functional MRI. By showing 
neurons at work, it allows us to spy on 
artists' brains and to watch their creative 
processes unfold. So, in an attempt to 
understand what parts of my brain engage 
when I Hsten to, read, think, or translate 
a piece of music, I submitted myself as a 
candidate for an experiment. While on a 
conducting assignment, I spent a week 
rehearsing an orchestra in Beethoven's Fifth 
Symphony. Between rehearsals I had my 
brain scanned while undertaking five dif- 
ferent activities: listening to a recording of 
Beethoven's music; thinking of the music 
but in silence, with my eyes closed; reading 
a score of Beethoven's Fifth in silence; 
moving my fingers as if playing the sym- 
phony on the piano, again in silence; and 
thinking of the motions I would use 
when conducting this music. 

The functional MRI revealed differ- 
ences in the responses in my auditory and 
visual cortices, as I expected. But dramat- 
ic differences also appeared in the asso- 
ciative areas of my brain, in the V4 region, 
the temporoparietal-occipital junction, 
the corpus collosum, and the Umbic sys- 
tem, regions whose interplay contribute 
to our perception of color. The experi- 
ment showed me how incredibly rich and 
varied the musical experience can be, a 
knowledge that gives me a greater under- 
standing for the diversity that audience 



56 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



ilip y\<iii'A] mMs in am plify one sense so ms Id rep kre (lie loss ofMnollier? —J 



response can take. It also provided me a 
startling glimpse of the responses that 
synesthetes — whose perceptual path- 
ways may be differently wired or, possi- 
bly, less disinhibited — can enjoy. 

Our growing knowledge of functional 
brain anatomy will allow us to continue 
gathering clues about artists' creative 
processes. In the same way, we can begin 
to capture the associative power of 
music and painting into art therapy. 
Some blind patients, for example, have 
found comfort in musical training, which 
has inducted them into a rich sonic 
world of subtle beauty. Visual patterns 
can be transformed into sound patterns 
for recognition and appreciation. Such 
synesthetic techniques can be helpful for 
patients with sensory loss. 

Breaking the Sound Barrier 

I often find comfort in late-night music. 
In Gustav Mahler's work I hear the end of 
mankind, as did the late Levws Thomas '37, 
an observation recounted in his book Late 
TSlight Thoughts on Listening to Mahlefs 'Ninth 
Symphony. But in Beethoven's Ninth, I hear 
and see a fist-shaking, gravity-defying, 



deaf-be-not-proud maestro and the 
indomitable spirit of mankind. 

My role as a conductor allows me to 
imagine the power offered by a synesthet- 
ic world. Sometimes, when I'm conduct- 
ing an orchestra, I'll close my eyes, and 
memories of past performances, a 
teacher's lessons, landscapes, colors, and 
the faces of musicians all flash together. 
Then the images disappear as quickly as 
they came, as a musical note evaporates in 
thin air after it is made. Only its memory 
and aftertaste linger in the mind, some- 
times for years or even a lifetime. 

Moving from the concert theater to the 
operating theater, I am often struck by 
how the brinkmanship inherent in the 
work of conductors also exists in the 
work of surgeons. When a conductor 
closes his score and his eyes to conduct a 
searing performance of The Rite of Spring he 
faithfully reproduces Igor Stravinsky's 
carefully calculated arrhythmias. One 
misstep, one deviation of a few milliseconds, 
and the fine synchronization and ensem- 
ble are threatened. Drums may lose their 
entrainment and rhythms unravel. 

During an eye operation, if a surgeon 
presses a few micrometers too deep, a 




phaco tip may penetrate the posterior 
lens capsule, and lens fragments may fall 
back to the retina. Fortunately, such 
comphcations rarely occur in either the 
musical or surgical endeavors. 

The accolades in both fields, when 
they occur, can be palpable. The applause 
in the chnic can be as resonant as that in 
a concert hall, though often quiet: The 
gratitude of patients shines through their 
eyes when, after cataract surgery, they 
rehve the wonder of unimpeded vision. 

It would give me great joy to be able 
to help artists regain critical sensory 
mechanisms they have lost, much as my 
surgery can help those encumbered by 
cataracts regain their view of the world. 
Our growing understanding of the neuro- 
mechanisms of sensory perception may 
make this possible one day. By learning 
how the brains of synesthetes process 
sensory stimulation and by comparing 
that information with that derived from 
experiments similar to my own, we may 
be able to rehabilitate those who — 
through stroke, aphasia, or other devasta- 
tions to their neural landscapes — have 
lost the ability to make those connections. 

To ensure that research and interest in 
"music medicine" grows, I have launched 
the Global Music Healing Institute, a 
foundation engaged in studying the effects 
of music on the autonomic system, on 
mood, and on speech and cognition. It is 
my hope that by stimulating research, 
pubhc awareness, and interdisciplinary 
knowledge of the medical benefits of 
music, this organization will help build 
bridges that will allow patients — perhaps 
even a Degas or Faure of today — reconnect 
with the perceptions and functions that 
help make their hves fuU. ■ 

Samuel Wong '88 has held music directorships in 
New York, Hong Kong, Hawaii, and Michigan. 
He has led the Royal Philharmonic on tour and 
recorded two award-winning discs with the Hong 
Kong Philharmonic. He now practices ophthal- 
mology in New York. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ANAT0M 

Doctor's 






THE NEWS TOLLED THROUGH THE CHILL 

air of the late winter dusk: Edward 
Augustus Holyoke was dead. The 
church bells were only the first of 
many to carry the message. Days later, 
the Salem Gazette would tell its readers 
that on the last day of March in 1829 
their town had lost "the skilful Physi- 
cian, the learned Philosopher, the active 
Philanthropist, and the Good Man" 
who had lived in their community 
for 80 of his 100 years. 




58 HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 




BIRTH PLACE: Its distinctive tower capped by a weathervane. Harvard Hall, shov/n here in a 1795 watercolor by Houdin 
Dorgemont, housed some of the early gatherings of students of the Medical Institution of Harvard University, the name by 
which Harvard Medical School v\^as first known. 



Two weeks earlier the Gazette had posted a short 
item warning readers that the "venerable" man 
was sick and his recovery doubthil. Now it was 
time for the community to pay its respects to 
Holyoke: a son of Edward Holyoke, a clergyman 
who had served as Harvard's president in the late 
1730s; a founder and the first president of the 
Massachusetts Medical Society; a charter member 
of the American Academy of Arts and Sciences; 
and the first person to receive a medical degree — 
albeit an honorary one — from Harvard. 

In keeping with the stature of the man, a 
newspaper notice for the funeral invited all to 
gather at Holyoke's home before processing to 
the church. But days earlier, in keeping with the 
nature of the man, Salem's physicians had been 



invited to convene what would be Holyoke's 
final contribution to the advancement of medical 
education: his autopsy. 

Cold Case 

Those physicians who could attend gathered in a 
room as chilly as the wintry outdoors. On a table 
before them lay Holyoke's draped corpse. 

Muffled by their cutaways and frockcoats, the 
men may have talked quietly as they stood around 
the table, smoked cigars or pipes, perhaps even for- 
tified themselves with Holyoke's prescription of 
"a dram of Rum or some spirit or a Glass or two 
of Wine." They may have intoned a prayer or raised 
a solemn toast. Then one of them, with little intro- 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



59 



d^.z> 



«-^^^^ *^'^U^^/^^'^j^^^ 



_^^l 



duction, had plunged a scalpel into the body's ster- 
nal notch. With that act, heads converged as the 
men leaned forward to learn the secrets of the 
death — and life — of their colleague and friend. 

Their investigation received assistance from the 
subject himself. A meticulous journal-keeper, 
Holyoke had described symptoms that had been 
troubling him during the previous three years. 
These included the sensation that water was mov- 
ing back and forth in his skull. "[I] perceived an 
odd and unusual sensation in my head when I sud- 
denly changed my posture... as if a moderately 
ponderous fluid fluctuated over the surface of the 
brain. ..." And indeed, the autopsy revealed that ' 
serous fluid had accumulated beneath the dura, i 
the thick parchment-hke membrane that sepa- ,' 
rates the brain from the skuU, a condition that - 
likely explained the sloshing sensation. 

Holyoke had also written of an abdominal 
pain that spiked after he ate. The physicians 
probing the final aspects of their former col- 
league found an explanation for this symptom, 
too — a large, most likely mahgnant, "schirrous" ' 
ulcer that girdled his stomach, dividing it into / 
two regions by a contraction so tight "as to 
hardly admit the passage of a finger." 

Aside from these conditions, the assembly 
found Holyoke's organs and "textures" to be in 
a surprisingly sound state more akin to those of a 
person five decades younger. But as to how this 
esteemed member of their community achieved his 
extraordinary longevity — and became the first 
Harvard man to pass the century mark — the 
autopsy gave httle insight. 

A Cabinet of Cure 



Born in Marblehead, Massachusetts, in August 
1728, "Neddie," as Holyoke was known to family 
and peers, was seven years old when his family 
moved to Cambridge so his father could serve as 
president of Harvard College. At age 14, Holyoke 
entered Harvard. After graduating in 1746 and 
spending a year as a teacher, he moved 
to Ipswich, Massachusetts, 
where he began the study 
of medicine as an appren- 
tice to Thomas Berry, a 



■J 

















MAN ABOUT TOWN: Known 
for keeping detailed and 
copious records of his patient 
cases and of his studies of 
natural phenomena, Holyoke 
also v/as an active corre- 
spondent on medical and 
social issues of the day. His 
interest in the details of life 
extended to his personal 
presentation. Until his final 
days, Holyoke went about 
Salem >vith a nosegay in the 
buttonhole of his dated but 
decorous clothing. 



~ -/»'/'>•».*.<- 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 




From age 20, the physician made his 
llculations, totaled neany i3U,uuO miles. 



well-respected local physician. Two years later, Holyoke 
relocated to Salem to set up his own practice. 

At first the decision seemed unwise: Holyoke had dif- 
ficulty building a patient base and so, for several years, 
seriously considered abandoning the town and his prac- 
tice. But a fear of distressing his father — and perhaps an 
early showing of the patience and perseverance that 
would come to characterize his approach to work — held 
him to the place and his practice. In the decades to come, 
his steadfastness would be amply appreciated. 

During his 80 years in Salem, Holyoke became a 
mainstay of the community, respected as much for his 
avocations as for his profession. His colleagues, for 
example, in their posthumous memoir — and autopsy 
report — of the man, described the town's indignation at 
the pilfering of a thermometer that had long been sus- 
pended from the doorpost outside Holyoke's home. The 
instrument was one Holyoke had regularly consulted 
as part of his long-term observation of weather condi- 
tions. The theft was "viewed as a sort of sacrilege, and 
it was generally agreed that it could not have been the 
deed of a Salem thief, for it was thought there could be 
none in town so base, as to not respect the property of 
the Salem patriarch." 

Holyoke was recognized throughout town, having 
ministered to the residents of nearly every Salem home. 
In his early years, his visits were on horseback. This 
mode of travel, however, did not work out well for 
Holyoke; he could not keep his steed from sHpping its 
bridle. So from age 20, the physician made his way on 
foot, an effort that, by his own calculations, totaled near- 
ly 150,000 miles. 

This man who, when seen on his way to the celebra- 
tion of his one -hundredth birthday, pleased passersby 
with " his elastic step and cheerful looks" and "his accus- 
tomed nosegay shpped through his button-hole," was 
also the man who impressed young doctors with the ele- 
gant simphcity of his practice of medicine. One such pro- 
tege wrote in 1797 of a conversation in which Holyoke, 
while showing the young man his shop, said, "there 
seems to you to be a great variety of medicines here . . . but 
most of them are unimportant. There are four which are 
equal to all the rest. Mercury, Antimony, Bark [quinine], 
and Opium; of these there are many preparations, how- 
ever. Of Antimony I think I have used thirty." 

Although seen as a cautious practitioner, Holyoke 
stayed current with new modes of practice and read the 
latest medical hterature; he was a long-term subscriber 



to many of the important journals pubhshed in England 
and on the Continent. He was one of the earhest physi- 
cians to experiment with the use of digitahs and other 
medicines, and colleagues acknowledged that there were 
"several medicines which owe their introduction into use 
entirely to him, and may in fact be said to have originat- 
ed with him, as he was the first to settle their best mode 
of preparation and administration." 

A Full Man 



Holyoke exhibited a zest for learning and life that 
seemed unquenchable, even in the face of personal 
tragedy; He lost his first wife and child in childbirth, 
and eight of the dozen children born to his second wife 
died in their first few years of life. 

In the memoir penned by his colleagues, Holyoke was 
described as someone who exemplified what Sir Francis 
Bacon had styled a "fuU" man, capable of speaking and 
writing Latin and French and "well versed in astronomy, 
and in the several branches of natural philosophy and the- 
ology, and the belle lettres." They wrote of how he 
admired the aurora boreaUs, compiled daily weather read- 
ings, and recorded his astronomical observations. And 
although they noted that he failed in his effort to correlate 
the prevalence of certain diseases with weather and sea- 
sonal changes, they were clearly impressed with his habit 
of chronicling his daily activities and observations. 

Notable among his recordkeeping efforts was his 
work during a smallpox epidemic that threatened Salem 
in 1777 An advocate of vaccination — Holyoke was him- 
self inoculated for smaUpox in 1764 — he was asked to 
head a smaUpox hospital just outside of town. Here he 
and his staff undertook the not-always-safe method of 
inoculating healthy individuals using extracts from the 
pox lesions of recovering victims. Of the six hundred 
people they vaccinated, only two died. 

Ten years later, Holyoke confronted a different epi- 
demic, this time of measles. During the several days of 
that event, Holyoke performed yeoman's service by daily 
making more than a hundred visits to patients through- 
out town. Even during quieter periods, Holyoke was an 
active practitioner, averaging eleven professional caffs a 
day. During both calamity and calm, however, he always 
took time to note the details of his visits to patients. 

The merits of keeping complete records seemed obvi- 
ous to Holyoke: "The observations of many, made at the 
same time, and in different parts of the country, and con- 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 




CRACKER JACK: James Jackson, the School's second dean 
and a cofounder of Massachusetts General Hospital, 
began his career as an apprentice to Holyoke. 



tinued for a course of years, must . . . doubtless be tfie read- 
iest and most effectual method of furnishing materials for 
a history of those diseases which are either epidemical or 
endemical in our country." Following his owti advice, 
Holyoke amassed 120 daybooks on his practice, each book 
filled with observations written in a fine hand. 

Although Holyoke's dedication to and exploits as a 
physician and intellectual were lauded while he lived, 
time has suggested that his more profound and lasting 
legacy may be that of a mentor and a pioneer in med- 
ical education. 

Bag Men 

Until Harvard Medical School was established in 1782, 
the apprentice system was the only method of physician 
education in New England. Some wealthy individuals 
were able to travel to Europe for their formal education 
in the field, but most doctors were trained by apprentic- 
ing themselves to an estabhshed practitioner. 

It was, and still is, a privilege to learn from a master. 
Indeed, even well into the twentieth century, many sur- 
geons spent time after their training working for highly 
experienced and respected surgeons. In the 1930s at 



Massachusetts General Hospital, surgical greats such as 
Richard Sweet '26 and Leland McKittrick '18 spent years 
as "assistants" to master surgeon Daniel Fiske Jones, 
Class of 1896, who had, in turn, spent years working 
under the famed surgeon Maurice Richardson, Class of 
1877. As late as the 1970s, young doctors "carried the bag" 
for older, successful, and experienced practitioners. 

Holyoke mentored many aspiring physicians; between 
1762 and 1817 he was preceptor to 35 medical men. Many 
of these men went on to estabhsh outstanding profes- 
sional records. James Jackson, a force behind the estab- 
hshment of Massachusetts General Hospital, provides 
one such example. A physician acknowledged for his 
comprehensive grasp of the needs of medicine and med- 
ical education in the early nineteenth century, Jackson 
regarded Holyoke as a "glorious old master." Another of 
the young men who learned from Holyoke became 
known for a range of accomphshments, including the 
instrumental role he played in the founding of Harvard 
Medical School. That young doctor was John Warren. 

In 1773, Warren moved to Salem to study with 
Holyoke and to open a practice. With time, he thought, 
he would be able to succeed Holyoke as the town's lead- 
ing physician. Things did not proceed as Warren had 
plarmed. A year had not passed before the young Warren 
was writing to his brother Joseph to complain that 
although he was busy and his practice was second only 
to Holyoke's in volume, he was unable to earn much 
income. "The people here are accustomed to being dealt 
with so very easy by their physicians," wrote Warren, 
"Dr. Holyoke having reduced fees to a very low rate and 
never troubled [his patients] for their accounts except 
when they troubled him for them." 

But the onset of the American Revolution presented 
Warren with an opportunity. His extraordinary talents 
as a surgeon were recognized, and he soon was com- 
manding hospitals for George Washington's army — and 
creating a name for himseff as a lecturer on anatomy. 
His skill and knowledge in this field ultimately led to 
Warren's appointment as the School's first professor 
of anatomy and surgery and to his appointment, with 
Jackson, as one of the first two staff physicians at 
Massachusetts General Hospital. 

Degrees of Separation 

The end of the American Revolution ushered in a vigor- 
ous time in this country, one that Holyoke participated in 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 



Holyoke's generosity m sharing his good fortune 
many of this country's tme medicai Uneages. 



with verve, founding and often leading many of the new 
professional, cultural, and historical associations. 

It was during this admirable frenzy that Harvard 
Medical School was born. Its origin was the result of a 
number of influences, including intense lobbying by 
Holyoke and other members of the newly formed Massa- 
chusetts Medical Society. 

It is unclear why Holyoke, among the many fine men of 
the period, was chosen to be the recipient of the first 
medical degree to be issued by Harvard, although few 
would have denied he was a deserving candidate. As a 
physician, he embraced new principles and methods and 
put them into practice, as exemplified by his smallpox 
vaccination work. His skills as an observer had allowed 
him to connect the disappearance of the once- common 
"dry belly ach" complaint with the disuse of lead-con- 
taining pewter dishes. And, as a scientist, his experi- 
ments on ether and the role of evaporation in lowering 
temperature had not gone unnoticed. 




SALEM FAILED HIM: After struggling to build a practice in 
Holyoke's Salem, John Warren left, a decision that proved 
beneficial to his career and to Harvard Medical School. 



Another strong contender for the honor may have 
been undone by the political climate of the time. James 
Lloyd, perhaps Boston's most prominent physician 
between 1765 and 1790, had spent time at Guy's Hospi- 
tal in London, where he had received training that sur- 
passed that of almost all his contemporaries in the 
colonies. But Lloyd was also a moderate royahst. That 
politically unpopular position could have tipped the 
balance on this momentous decision; the degree, after 
all, would be conferred in 1783, just as the nation was 
breaking free of England. Although Holyoke was also 
well acquainted with the Tory crowd, in 1775 he had 
joined others in writing a public declaration disavowing 
any support of Royal Governor Thomas Hutchinson and 
declaring opposition to English rule. 

In addition to having the right political stance for 
the times, the role that Holyoke's connections played 
in the decision to award him this degree cannot be 
minimized: He was, of course, the physician-son of a 
former president of Harvard. And, as the first presi- 
dent of the Massachusetts Medical Society, Holyoke 
worked with two of its other founding members, 
Warren and Aaron Dexter. These men, who represent- 
ed two-thirds of the School's first faculty, undoubted- 
ly helped influence the decision. 

Climate Change 

The hundred years of Holyoke's Me coincided with a 
period of great change in the country's history. The 
emphasis on rehgion in daily life shifted, and society 
became more secular and tolerant. The intellectual 
awakening of the period saw a flowering of hterature 
and newspapers and the introduction and acceptance of 
modern scientific ideas, methods, and teachings. A 
strong democratic society emerged, one that clearly 
announced its rejection of the rigid class system of its for- 
mer colonizer. 

Holyoke was a product of this intellectual and 

scientific ferment. His generosity in sharing his good 

fortune and talents with his students helped estabHsh 

many of this country's fine medical lineages and led to 

the formation of some of the more important medical 

and intellectual institutions, many of which stand tall 

even today. ■ 

Anthony S. Patton '58 is a retired thoracic and vascular surgeon 
whose career was centered at Salem Hospital in Massachusetts. 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ATJIMNA P ROFTT.F 



JANET REGIER '81 



Cold Calling 




ANET REGIER '8l HATES WINTER. BUT THE SELF-DESCRIBED 

"outdoors unenthusiast" wouldn't take back a single 
moment of her Antarctic experience — not the igloo- 
building; not the ritual touching of the post staked at the South 
Pole; not the altitude sickness, the bulky gear, or the hat that gave 
her an uncanny resemblance to Marge Simpson; and especially not 
the sushi, eaten polar style, fresh from beneath the ice. 



"One day I was taken to the laboratory of 
a scientist who studies fish blood for its 
antifreeze qualities," Regier recalls. "He 
had fed a winch under the Ross Ice Shelf 
and puUed up a huge Mawson cod. After 
tagging the fish, he served up, in the cor- 
rugated metal shack that housed his labo- 
ratory, fresh cod cheeks with chardonnay. 
They were deUcious." 

Regier's job brought her to that shack 
on the world's largest ice shelf in the 
height of the Antarctic summer in 2002. 
As the medical director of the National 
Science Foundation's health unit in 
Arlington, Virginia, she evaluates scien- 
tists and staff for their fitness for the 
extreme environments of the organiza- 
tion's polar program. 

Her journey to Antarctica helped her 
understand the medical capabilities avail- 
able at McMurdo Station, the main scien- 
tific base there, and experience the condi- 
tions firsthand. "After my trip," Regier 
says, "I began interpreting the mission- 
readiness criteria in much stricter fashion, 
especially when making evaluations of car- 
diovascular and endocrinological fitness." 

She encounters tough cases that fall 
neither within nor without the polar pro- 
gram's guidelines. She worried, for exam- 
ple, about one scientist whom she'd 
approved for the assignment despite his 
earher kidney transplant. Although she 
had wrestled with her original decision to 
clear him for duty at the Pole, Regier was 
reassured by her observations of the man 
on-site. "After seeing him in action out- 
doors," she said, "I didn't hesitate to 
approve him for the following year." 



Regier discovered that healing takes 
longer at the Pole. "A laceration doesn't 
always anneal because it's so cold there," she 
says. "Sometimes you have to use superglue 
to coax it along." Dental fillin gs fall out. And 
other nuisances, such as a hangnail or any 
ordinarily minor threat to physical com- 
fort, can quickly escalate to obsessions. 

"The two days I was outside at snow 
school I couldn't find my mug," Regier says. 
"And all I could think about was if I just 
had my mug, I could wrap my hands 
around it and be warmer. We always try to 
alleviate pain, so when we can't, we per- 
severate on it. Such fixations can sour the 
whole experience if you let them." 

The nearly 1,100 people stationed at 
McMurdo include not only scientists 
peering at ice cores, sea stars, and the 
stars above, but also the cooks, electri- 
cians, carpenters, and computer techni- 
cians who keep the base running. Regier 
evaluates and advises some of them, too, 
before they head south. "Many accidents 
happen because of the ice," she says. But 
shcing skin off a knuckle while peeling 
potatoes or losing one's grip on a hammer 
can also result when the cold stiffens 
digits and hmbs. 

"We employ many physical therapists 
who teach the workers to stretch before 
going on duty, sort of hke a morning yoga 
class," Regier says. "The workers grum- 
bled about this at first, but stretching has 
definitely reduced the rate of accidents." 

Health care gets comphcated at the 
Pole, she adds. "After February 25, it 
becomes logistically impossible to extract 
people from the base for about six 



months. That's why the 20 people or so 
who overwinter at the Pole each year are 
required to submit to more rigorous fit- 
ness evaluations. The added scrutiny 
includes a gallbladder ultrasound to 
check for stones or sludge and, for female 
researchers, a pregnancy test. 

And yet no amount of chnical screening 
can prevent every health emergency. 
While working at McMurdo, Regier wit- 
nessed a telemedicine consultation with 
specialists at the University of Texas 
Medical Branch in Galveston. The clinic's 
physicians sought help with the case of a 
young man who had contracted viral peri- 
carditis. Fortunately, the patient's peri- 




cardial effusion resolved, eliminating the 
need for off- continent medical transport. 

A Desert Isle 



Regier was surprised at the clinic's decid- 
edly low-tech appearance despite its 
high-tech telemedicine, skilled physi- 
cians, and state-of-the-art decompres- 
sion chamber for research divers. "The 
beds look hke something out of M*A*S*H," 
she says, "with pulleys for traction and 
huge, nearly obsolete oxygen tanks." 

But the lack of dehcate equipment 
makes sense in a place where conditions 
are often harsh. Because Antarctica is a 
desert, water is rationed; people at the Pole 



64 



HARVARD MEDICAL ALUMNI BULLETIN • SPRING/SUMMER 2007 




BED OF ICE: Janet Regier 
spent time at sno>v school 
near the South Pole, cutting 
blocks of ice from a glacier 
to build her night's shelter, 
an igloo. 



muskox looks down like that and makes 
a noise, it's not good. I pedaled away as 
fast as I could." 

Regier notes that many of those 
working in the Arctic also work in the 
Antarctic, switching Poles when the 
nights grow longer than the days. They 
become specialists in extreme environ- 
ments and perhaps addicted to so much 
daylight. Regier says they jokingly 
describe themselves as "bipolar." 

March of the Scientists 



With 2007-08 marking the International 
Polar Year — the 50th anniversary of the 



Many of those working in the Arctic also work in the Antarctic, switching H 
Poles when the nights grow longer than the days. They become specialists 
in extreme environments and jokingly describe themselves as "bipolar." 



may shower only once every week or two. 
Ironically, Regier says, fire also poses a 
major concern despite all that ice. So the 
scientists and others joined forces to cre- 
ate a volunteer fire brigade. 

Beyond the base, closer to the Pole, con- 
ditions become even more extreme. Regier 
spent two days in snow school getting 
survival lessons in case of catastrophe. 
She learned to make an igloo, for example, 
by cutting ice blocks with an ice saw. 

She also experienced altitude sick- 
ness, a common affliction at the Pole, 
which sits some 9,000 feet above sea 
level. A three-hour flight in a cargo plane 
across the TransAntarctic Mountains 
took Regier to the Pole, without any 
chance to acclimate. During her two days 
there, she suffered severe headaches. She 
now regularly screens patients for a his- 
tory of high- altitude pulmonary or cere- 
bral edemas, knowing that a person who 
has experienced it once has a 50 percent 
chance of a repeat bout. 



Yet the geography also penetrates the 
gray matter in ways that seem to ease 
headaches. "It's incredibly beautiful in 
Antarctica, an icy Shangri-la," Regier says. 
"Everything is north of you. The real world 
feds far away. You think differently there." 

Close Encounters 



After hving briefly 75 degrees south of the 
equator, Regier headed for an island 75 
degrees north of that line — Greenland. 
Her May 2005 visit seemed practically 
bahny after the South Pole. "We had beau- 
tiful, long, sunshiny days," she says. "It was 
50 degrees the day I arrived." 

The highlight of her experience there 
was an encounter with local wildlife. 
"I'd taken a mountain bike up to Russell 
Glacier," Regier says, "and on the 
descent I spotted a muskox — looking 
like a small woolly mammoth, so hairy 
you could hardly see his eyes — on a hill, 
staring down. I had read that when a 



global decision to use the Poles for peace- 
ful rather than military purposes — it 
seems appropriate that Regier will be 
returning to the Antarctic next spring. 
But this time she'U travel to the peninsu- 
la just off the tip of South America known 
as the "Banana Belt." 

Its relative warmth allows cruise ships 
to ferry tourists there to watch Adehe 
and Emperor penguins frohc on the ice- 
bergs. Regier's ship, however, won't be a 
luxury hner but a research vessel or an 
icebreaker. She'll be considering the par- 
ticular hazards on board the ship and, 
once she's on the peninsula, she'll be eval- 
uating the health unit at the base there, 
where 60 people work and hve. But on 
that visit she also hopes to turn tourist 
for a few moments, to seek out some wad- 
dhng, fhghtless birds on her own. ■ 

]anicc O'Lcary is assistant editor of the 
Harvard Medical Alumni Bulletin, a com- 
fortahle 42 degrees north of the equator 



SPRING/SUMMER 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



65 




1 





n 


Cd 


M 


X 


Qrq 

IT) 


O 
w 

r-t 
O 

3 


CD 


D 
Q 


0) 


S 


r-r 
C 


Q. 


< 
n' 
ro 


CO 

n 

d 


CA) 
r-f 

0> 


<p 
a. 

n* 


XI 


n> 




Q_ 


C 


rt 






ro 


rt 






CZ) 


cn 

O 




> 






C 

3 








5. 
















> 








w 








M 












l\ / 





o 2 
o 3- 



C 

O 
en 
r-r 

era 



z 


3 

o 



NEW KID ON THE BLOCK: The latest member 
of the patient simulation family at Harvard 
Medical School can cry, wet, and, in response 
to oxygen deprivation, turn blue. 



o 

Q 
3^ 

5' 

D 

5' 

3